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THE
CHIRURGICAL WORKS
OP
PERCIVALL POTT, F.R.S.
SURGEON TO ST. BARTHOLOMEW'S HOSPITAL.
WITH HIS LAST CORRECTIONS.
TO WHICH ABE ADDED,
A SHORT ACCOUNT OF THE LIFE OF THE AUTHOR,
A METHOD OP
CURING THE HYDROCELE BY INJECTION,
AND OCCASIONAr,
NOTES AND OBSERVATIONS.
SIR JAMES EARLE, F. R. S.
SURGEON EXTRAOHDINAHT TO THE KING, &C.
A certis potius et exploratis petendum esse preesidium; id est, his qua: Experientia in ipsis
curationibus docuerit ; sicur in eaeteris omnibus actibus : nam ne agricoiam quidem aut gubernd-
torem disputatione, sed usu fieri. A. CORN. CELSUS.
FIRST AMERICAN, FROM THE LAST LONDON EDITION.
IN TWO VOLUMES.
VOL. I.
PHILADELPHIA:
PUBLISHED BY JAMES WEBSTER, NO. 24, SOUTH EIGHTH STREET.
William Brown, Printer.
■ ' 1819.
""""^^r^/^
4^/
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CONTENTS OF VOL. I.
Page
A SHORT Account of the Life of the Author .... - i
Observations on the Nature and Consequences of those Injuries to
which the Head is liable from External Violence - - - - 29
Wounds of the Scalp 31
Effects of Contusion on the Dura Mater, and Parts within the Scull 44
Contusion with Wound 63, 65, 76, 78, 83
without Wound - - - - - . 67, 70, 73, 74,
Contusion joined with Extravasation ------ 80
Separation or Destruction of both Tables of the Scull from Contusion 85
Fissures and Fractures of the Cranium without Depression - - 94
Simple Fracture .--.--.--- 121
Fractures of the Cranium with Depression ... - - 135
Extravasation and Commotion -.....- 148
Observations on that Disorder of the Eye commonly called Fistula
Lachrymalis - ..-.----- 179
General Remarks on Fractures and Dislocations . - - . 217
Compound Fractures -...----- 265
Of Dislocations in general ....---- 287
A Treatise on Ruptures --------- 305
Those capable of easy and immediate Reduction - - - - 323
Those that are found irreducible, but not in a State of Inflammation 327
Those which are reducible, but attended with Pain and Hazard - 333
Those which are in such a State as to be irreducible by the mere
Hand, and in which a Chirurgical operation is necessary for the
Preservation of the Life of the Patient 341
Parts composing a Rupture, when so diseased as to be unfit for imme-
diate Reduction, what then becomes necessary - . - - 358
Ruptures in Females -.-.....- 367
The crural or femoral Hernia - - - - - - -370
The congenial Hernia --. 372
The umbilical Rupture ..--.--- 376
The ventral Hernia, &c. ..-.---- 380
Attempts toward a radical Cure 382
Observations and Cases relative to Ruptures ... - 391
Intestinal Herniae 406
Congenial Herniae .....----. 418
Hernia Vesicae Urinarise - - -- - - - - 433
An ovarian Hernia ....--.--- 436
yoL. I.
SHORT ACCOUNT
M^ mw
A SHORT ACCOUNT, ^c.
At the time of Mr. Pott's decease, very few copies
of his works remaining in the bookseller's hands, I was
prevailed upon to superintend and publish a new edition
of them: this, also, having been some time since ex-
hausted, a similar application has been made to me rC"
specting another edition.
The encouraging reception of the former, and the
high respect which I must ever retain for the author^
are sufficient inducements again to lend any assistance
in ,_my power to promote the circulation of his valuable
instructions.
The writings of Mr. Pott had been universally readj
and many of his improvements in the practice of surgery
had come into general use, for several years before his
death. Most of his opinions have stood the test of ex-
tensive experience; and it is hardly to be doubted, that^
whatever improvements have since been or may here-
after be made in this progressive art, his works will be
esteemed as a valuable monument of genius and of skilly
for the times in which the author lived, to the latest
posterity.
The event which put a period to the useful labours
of Mr. Pott also closed his account of them; as, to the
great disappointment of the medical world, little new oja
IV A SHORT ACCOUNT OF THE
any chirurgical subject was discovered among tlie papers
of an author, whose pen was seldom long unemployed.
This was not the effect of accident or inattention, but
of design, for the last years of Mr. Pott's life were not
less industriously spent than the earlier part; nor was
the spirit of inquiry or of emulation at all diminished by
his advanced age, but he had given his friends every
reason to expect that no manuscript would be left; and
often censured, in strong terms, the imprudence of au-
thors leaving imperfect papers behind them, which their
relations seldom have discretion or disinterestedness
enough to suppress. My constant intercourse with him,
both on business and in his leisure hours, gave me an
opportunity of knowing his sentiments on some subjects
which had occurred since his last publication. Such of
these as materially affected the doctrines he delivered,
were noticed in the last edition ; and have endeavour-
ed, in the present, still further to correct, arrange, and
add, whatever has appeared to me likely to contribute
to tlie general usefulness of the work.
To my last edition I prefixed a short historical ac-
count of the author's life, which I presume will not be
unacceptable to the readers of this: the thoughts, the
conduct, and actions of celebrated men have been gene-
rally considered interesting and useful.
My near connexion with the family of Mr. Pott fur-
nished me with the most authentic information con-
cerning every transaction of his life whicli could in any
way interest mankind, and having been already faithfully
and correctly detailed, will be reprinted with very few
alterations.
Percivall Pott was born on the 26th of December,
171 S, in that part of Threadneedle-street which is now
LIFE OF MR. POTT. V
the site of the new Bank-buildings. His father, whose
Christian name was Percivall, married the widow of
Mr. Houblon, son of Sir Jacob Houblon; and, in 1717,
left her again a widow, and him, their only son, with
means very inadequate to their support. The deserted
state of Mrs. Pott, joined with a deserving character,
and many excellent qualities, could not fail of engaging
the attention of her friends, among wliom was Dr. Wil-
cox, bishop of Rochester, her distant relation, who took
her son under his immediate patronage. Thus she was
enabled to pursue a plan for his education and future
views in life, which were the principal objects of her
maternal sohcitude. Mr. Pott returned her tender care
with the utmost affection. Indeed, so enthusiastic was
his love for his mother, so great the obligations which
he always conceived he owed to her, and so unimpaired
by time was his remembrance of them, that, to the last,
he never mentioned her, but in terms expressive of sen-
sibility and gratitude.
When seven years old, he was sent to a private school,
at Darne in Kent, where the instructions, though very
confined, were, to a mind of his quick conception, suf-
ficient to form an early taste for classical knowledge;
which, by his own assiduity, without further assistance,
was afterwards improved to critical accm'acy.
Mr. Pott showed, very early, a strong propensity to
the profession of surgery. Some of his best friends re-
commended the church, in which he had no inconsider-
able prospects of preferment; but neither advice nor
persuasion could alter his fixed determination. He was
accordingly, in 1729, bound an apprentice to Mr.
Nourse, one of the surgeons of St. Bartholomew's hos-
pital. In this situation he had great opportunities of
Vl A SHORT ACCOUNT OF THE
improvement, particularly with regard to anatomy, which
was at that time little cultivated in London. Mr. Nourse
was one of the few who then gave anatomical lectures;
his school w^as at London-house, in Aldersgate-street;
and Mr. Pott was employed in preparing the subjects
for demonstration, which laid the foundation of his accu-
rate acquaintance with that science, the basis of chi-
I'urgic knowledge. In the hospital he found unlimited
opportunities of studying the nature and progress of dis-
eases, and of observing practical surgery.
At that time the art was miserably defective; the in-
struments were clumsy and unmanageable; the opera-
tions unscientific, and unnecessarily painful: the esta-
blished mode of practice, incumbered with a farrago of
useless medicines and applications, tended rather to
mislead than direct the inquirer; prescription too fre-
quently held the place of reason; and want of real know-
ledge was concealed under a pompous garb and specious
demeanour. Though labouring under these disadvan-
tages, his intuitive genius soon led him to discriminate
between right and wrong, taught what to adopt, what
to reject; and enabled him afterwards to break through
the trammels of prejudice and custom. During his ap-
prenticeship, his natural vivacity did not prevent the
appli^-^ation of a very considerable portion of his time to
the study of authors in every branch of surgery. Very
early in life, he adopted Lord Bacon's advice to a stu-
dent, to consider one part and one disease at a time, and
to become thoroughly acquainted with that before he
undertook another: on that plan, he never quitted the
immediate object of his inquiry, till he had traced it to
every source of information.
Mr. Pott always professed great value and respect for
LIFE OF MR. POTT. VIJ
the early writers on the art, and perused then* volumi-
nous works with great diligence and sagacity. He fre-
quently observed, that though no great advantage could
be derived from them in the practical part, yet whoever
studied them would be amply repaid, by their accurate
description of diseases, which they portrayed from na-
ture. But his reading was not confined to professional
books; it was various and extensive; and I think I may
venture to say, that his memory never suffered any thing
to escape which he had once thought worthy a place in
his mind.
In 1736, at twenty-two years of age, having finished
his apprenticeship, he immediately applied himself to
business. Confident in the fair prospects of industry,
he hired a house, of considerable rent, in French-
church-street, and took with him his mother, and her
daughter by the first husband. Such a young man
could not long remain unnoticed: the assistance which
is given at the entrance into life is most valuable and
most disinterested. Of this Mr. Pott was perfectly sen-
sible, and always acknowledged with gratitude the obli-
gations which he owed to the fostering favourers of his
youth. As the brilliancy of his talents brought his con-
versation into much request, his connexions were soon
universally extended. Besides the families to which his
profession introduced him, he became acquainted vi'ith
most of his cotemporaries of rising and eminent abilities
in every profession. The early friendships which he
formed were permanent; and it may truly be asserted,
that few men have acquired and retained througTX: life
more firm or more respectable friends.
In 1744-5, he was elected an assistant-surgeon, and
in 1749 he was appointed one of the principal surgeons
Vlll A SHORT ACCOUNT OF THE
of St. Bartholomew's hospital. He had now before him
sufficient scope for the exercise of those abihties by
which mankind have since been so much benefited.
The state of surgery was still very imperfect, notwith-
standing some sensible and ingenious men, both in this
country and in France, had published observations which
had enlightened and improved it: still the maxim, " Do-
lor medecina doloris," remained unrefuted; the severe
treatment of the old school, in the operative part and in
the applications, continued in force; the first principles
of surgery, the natural process and powers of healing,
were either not understood or not attended to; painful
and escharotic dressings were continually employed;
and the actual cautery was in such frequent use, that,
at the times when the surgeons visited the hospital, it
was regularly heated and prepared as a part of the ne-
cessary apparatus. In the works of several authors,
who flourished in the early part of our author's life, we
have contrivances for improving these dreadful instru-
ments. Mr. Pott's tutor rigidly adhered to the establish-
ed practice, and treated with supercilious contempt the
endeavours of his pupil to recommend a milder system.
But the dictates of truth soon found a welcome recep-
tion with the profession, and with the world in general.
Mr.' Pott lived to see these remains of barbarism set
aside, and a more humane and rational plan, of which
he was the chief author, universally adopted. Surgery,
being thus divested of great part of its horrors, became,
comparatively, a pleasing study; for, except on those
unfc«itunate occasions, when the humane feelings of the
practitioner must suffer, from the unavoidable necessity
of giving pain, the aim and end of the healing art are
surely pleasing. To possess the power as well as the
LIFE OF MR. POTT. IX
inclination to relieve distress, to soften anguish, and in
some measure to break the force of those accidents and
misfortunes, to which mankind are always liable, must
afford to every feehng mind the greatest and most sin-
cere pleasure which it is capable of enjoying.
Mr. Pott's affection for his mother prevented him
from forming any attachment during her life, which
might separate him from her. In 1 746, being, to his
sorrow, released from this filial engagement, he remov-
ed to Bow-lane, and married the daughter of Robert
Cruttenden, Esq. \ a lady of whom every thing commend-
able might justly be said, and who, in mental and per-
sonal accomplishments, was formed to be his compa-
nion.a
In the year 1756, an a;ccident befel Mr. Pott; which,
though of little consequence in itself, yet, as it displays
the vigour and firmness of his mind, and seems to
have had considerable influence on his future life,
deserves to be recorded in this place: — As he was
riding in Kent-street, Southwark, he was thrown from
his horse, and suffered a compound fracture of the leg,
the bone being forced through the integuments. Con-
scious of the dangers attendant on fractures of this na-
ture, and thoroughly aware how much they may be in-
creased by rough treatment, or improper position, he
would not suffer himself to be moved until he had made
the necessary dispositions. He sent to Westminster,
» I may now add (1808), that, at the age of 86, Mrs. Pott still retains
her excellent understanding and faculties unimpaired. In society, cheer-
ful and interesting, with strong powers of recollection and judgment, she
attracts around her the young, the old, the grave, and the gay ; and, with
a pen equal to that of Madame De Sevigne, instructs and delights a nume»
rous set of correspondents.
VOL. I, B
X A SHORT ACCOl/NT OF THE
then the nearest place, for two chairmen, to bring theh'
poles; and patiently lay on the Qoid pavement, it being
the middle of January, till they arrived. In this situa-
tion he purchased a door, to which he made them nail
their poles. When all was ready, he caused himself to
be laid on it, and was carried through Southwark, over
London-bridge, to Watling-street, near St. Paul's, where
he had lived for some time — a tremendous distance in
such a state! I cannot forbear remarking, that on such
occasions a coach is too frequently employed, the jolting
motion of which, with the unavoidable awkwardness of
position, and the difficulty of getting in and out, cause a
great, and often a fatal aggravation of the mischief At
a consultation of surgeons, the case was thought so des-
perate as to require immediate amputation. Mr. Pott,
convinced that no one could be a proper judge in his
own case, submitted to their opinion; and the instru-
ments were actually got ready, when Mr. Nourse, who
had been prevented from coming sooner, fortunately
entered the room. After examining the hmb, he con-
ceived there was a possibility of preserving it: an at-
tempt to save it was acquiesced in, and succeeded. This
case, which Mr. Pott sometimes referred to, was a
strong instance of the great advantage of preventing the
insinuation of air into the wound of a compound frac-
ture; and it probably would not have ended so happily,
if the bone had not made its exit, or external opening,
at a distance from the fracture; so that, when it was re-
turned into the proper place^ a sort of valve was formed,
which excluded air. Thus no bad symptom ensued,
but the wound healed, in some measure, by the first in-
tention.— The appearance of Mr. Pott as an author
LIFE OP MR. POTT. X»
was an immediate effect of this accident.'' During the
leisure of his necessary confinement, he planned, and
partly executed his Treatise upon Ruptures, which was
completed by the latter end of the year. It was then
not an early period of his life: and it is possible that the
busy scene in which he had hitherto been engaged,,
might have occupied his mind much longer. As he
had been thus led on to the age of forty-three, it is by no
means impossible that, without some powerful check to
the train of his pursuits, he might never have discovered
in himself those superior powers of scientifical disquisi-
tion, that correct taste and masterly command of language,
which have placed him in the first rank of medical wri-
ters. Engaged, from early youth, in the constant trans-
action of business, he probably till this period had in--
dulged but little in the pleasures of speculative investi-
gation, but was never afterwards long unemployed in
some literary work. Indeed, the flattering reception of
his pubhcations, and the gratification of communicating
to the world scientifical improvements, would have been
sufficient to confirm a mind, less ambitious of fame than
hi«, in the habits of an author.
In 1757 he wrote an account of the Hernia Congenita,
a complaint not then well understood. Dr. William
Hunter, the celebrated anatomist, who was engaged in
the same pursuit, inserted a paper in the Medical Com-
mentaries, claiming a priority in the discovery. But I da
not mean to enter into the merits of a dispute, which,
•> I do not find that Mr. Pott had written any thin^- previous to this, ex-
cept the relation of a curious case of tumours, by which the bones were
softened. This was presented to the Royal Society soon after he began
business, and may be found in the 2d part of the 41st volume of the Philo-
sophical Transactions. — It is also inserted at the end of the 2d Vol. of these
Works.
XU A SHORT ACCOUNT OP THE
though at that time it caught the attention of the medi-
cal world, is now nearly forgotten. Mr. Pott's reply
was inserted in the second edition of his Treatise on
Ruptures, and is written with elegance and urbanity.
His observations on the disorder of the corner of the
eye, commonly called Fistula Lachrymalis, appeared in
1758. This sensible, well written performance on a
complaint which frequently occurs, has, both in matter
and manner, considerable merit. In it he explains the
situation, describes the various appearances of the dis-
ease, and simplifies the method of cure: his arguments
were the principal cause of discontinuing the operation
by the actual cautery, which was practised and recom-
mended by Mr. Chesselden, who flourished in the early
part of our author's hfe.
In 1760 was produced his elaborate performance on
the nature and consequences of wounds and contusions
of the head, fractures of the scull, concussions of the
brain, &c. in which, with a perspicuity till then un-
known, he separates and arranges the symptoms of each
particular species of injury, unfolds the causes and situ-
ation of mischief, and points out the most probable
means of relief.
In 1 162 he published Practical Remarks on the Hy-
drocele, and some other diseases of the testis, its coats,
and vessels, illustrated with cases; being a supplement
to his general Treatise on Ruptures.
In 1764 he had the honour to be elected a Fellow of
the Royal Society; at the same time, he presented them
with a curious and uncommon case of a hernia of the
urinary bladder, including a stone, which is inserted in
the Philosophical Transactions, Vol. LIV.; and also at
the end of these volumes.
LIFE OF MR. PO.TT. XUl
As the activity of Mr. Pott's mind was equal to his
zeal for the advancement of the art, wliatever subject
appeared to him to have been least considered, or most
defectively treated by others, immediately became the
object of his researches, and engaged his particular at-
tention. The fistula in ano next attracted his notice.
The nature of this complaint had been much mistaken,
and the operations for its relief vt^ere consequently inju-
dicious, horridly severe, and destructive of the parts
they vi^ere intended to relieve. In 1765 he published a
treatise on this subject. His method of reasoning on it
is clear, ingenious, and conclusive; but they only can
be judges of this inestimable work who have compared
the simple operation which it recommends with those
usually practised in similar cases in this kingdom, until
the latter part of Mr. Pott's life, and even at the present
time in other countries.
The observations and instructions which thus flowed
from his ready pen, were enforced by his practice, and
illustrated by oral communication; and he was happy to
embrace every opportunity which his situation gave him,
of conveying the information he had collected to those
w^ho had not the same means of acquiring it.
The humane and benevolent disposition of the people
of this country is eminently displayed in the many cha-
ritable institutions which abound for the relief and pro-
tection of the poor, and in the ample support of them.
The beneficial influence of hospitals is not shut up
within their walls, nor confined to the objects who are
there relieved; the blessings which are there distributed
revert to their opulent and noble supporters, and are
extended to all ranks and conditions of men, by the im-
provements which the medical art receives from the stii-
XIV A SHORT ACCOUNT OF THE
dents who frequent them. In a large hospital there
must be opportunities of seeing the greatest possible va-
riety of diseases, such as are either produced or increas-
ed by negligence and intemperance, added to those
which are met with among the more prudent and better
informed part of mankind. In short, all the multiform
deviations from health and natural perfection are there,
as in one large volume, collected and displayed. Of
the advantages arising from such a collection, no person
could be more sensible than Mr. Pott; but he also judi-
ciously remarked, that young men often stood in need
of an index to point out to them the proper objects for
their attention and inquiry. To supply the deficiency,
about this time he instituted a course of lectures, the
first of which was given at his house in Watling-street.
He had not then digested and arranged his ideas, but
spoke, as I well remember, with hesitation and reserve:
yet even these his first essays bore strong marks of his
comprehensive and penetrative mind. In a few courses
he overcame all obstacles, and communicated his
thoughts with eloquence and ease. He was not satis-
fied with following any system which had been laid
down by others, as he thought they in general dwelt too
much on the operative part, which, though veiy impor-
tant, is by no means the most difficult part of surgery,
nor the most worthy of attention. The means of pre-
venting the necessity of operations, he observed, should
be the first consideration; he therefore formed a plan of
his own, the best, perhaps, which could be devised. He
began with such general disorders as may affect any
part of the human frame, and afterwards proceeded to
consider the diseases of each part distinctly, beginning
with the head, and descending to the inferior members.
LIFE OF MR. POTT. XV
He took great pains on every point; and, having the art
of being minute without tediousness, demonstrated it
with clearness and precision. His manner gave impor-
tance to every subject, and impressed his audience with
the idea, that the art which he taught was worthy of
their highest ambition. He not only explained the best
modern practice with his own observations, but ren-
dered the lecture still more curious and interesting, by
a review of the practice of the ancients, and of the gra-
dual progress of improvement which had taken place.
This his extensive perusal of authors of all ages had
made easy to him; for there was no time of his life when
he thought so highly of himself as to imagine that he
could receive no light from books. He often said, he
began to teach when he had much to learn; and, as he
was not actuated by that opinionative wisdom which
sometimes attends advanced hfe, after all his study and
experience he confessed, that he still retained a long
list of inquirenda. His lectures were constantly at-
tended by a numerous succession of pupils, and have
been the means of very extensively disseminating much
useful knowledge.
In 1 768 he produced a new edition of his book on
the Injuries to which the Head is liable from External
Violence, accompanied with what is entitled A Few
General Remarks, but which is really a complete sys-
tem on fractures and dislocations. This, I have been
informed, he began and completed in a fortnight. The
novelty of the doctrine contained in this treatise relates
principally to the position of the injured limb. On its
publication it met with some opposition, but has now
subdued the first prejudices; and I beheve I may ven-
ture to say, is become almost the universal practice.
XVI A SHORT ACCOUNT OP THE
The frequent avocations of Mr. Pott towards the west
end of the town, where the buildings had prodigiously
increased since he began life^ making a more central
situation necessary, in 1769 he purchased a house near
Lincoln's-inn Fields, and resided in it seven years, dur-
ing which time his pen was not inactive. The hydro-
cele again employed his thoughts. In 1772 he sent to
the press his improved method of passing the seton, so
as not to rub or injure the gland in its passage.
Mr. Pott took great pains with this subject, and
never was perfectly satisfied with what he had done in
it. Various other methods have been employed for the
cure of this complaint, and practitioners are still divided
between them. I must confess that the curative inten-
tion does not seem well answered by either of them:
they all appear to me to raise more inflammation, and to
derange the economy of those tender and sensible parts
more than is necessary. I have proposed another, which
answers the purpose in a milder and better manner than
any I have yet seen; and I feel a satisfaction in saying,
that it met with Mr. Pott's approbation. One of our
last conversations was on this subject; and, if his life
had been prolonged, it was his intention to have prac-
tised it.
In 1775, Mr. Pott published Chirurgical Observa-
tions relative to the cataract, the polypus of the nose,
the cancer of the scrotum, the different kinds of rup- ,
tures, and the mortification of the toes and feet, which
were valuable additions to his former publications, and
were marked with that spirit of observation, perspicuity
of reasoning, and candour in discussing controverted
points, which distinguish his other productions.
In 1777 he removed to Hanover-square. Here, at
LIFE OF MR. POTT. XVU
an age when most men begin to think of ease and
retirement, his active mind led him into a scene more
busy and extensive than ever. Sir Cassar Hawkins,
who had long been employed in many of the first fami-
lies, retired from London, which made no inconsiderable
addition to Mr. Pott's former connexions. But, though
engaged in business by day, and occupied at home in
the evening, in answering letters addressed to him from
all parts of Europe, I might say of the world, having
seen many letters in which he was consulted on cases
from America, Russia, Turkey, and India, as well as
from our neighbouring kingdoms, he contrived to find
time to add to his former w^orks a treatise on the ne-
cessity of amputation in certain cases, in which he ar-
gues strongly in favour of truth and humanity, and
clearly proves the rectitude of the principles which he
has laid down. This seems principally to have been
written in answer to Mr. Bilguer, surgeon to the army
of the late King of Prussia, who had pubhshed against
the necessity of amputating in almost any case. The
title of his book is, "De Membrorum Amputatione
"rarissime administranda, aut quasi abroganda;^^ and
also, in reply to his commentator, Mr. Tissot, who
wrote a treatise, " Sur I'Inutilitt; de TAmputation des
" Membres,'" in which he goes even beyond his origi-
nal, and absolutely sets aside the operation as useless;
he speaks of it in the most opprobrious terms; he is
shocked at the horror of it; exhorts surgeons to aban-
don the murderous and cruel method of amputation,
with many other expressions equally misapplied. Such
futile and absurd imputations can never confute what
reason and experience have joined to demonstrate, that
many Hves have been saved by the operation, which
VOL. r. c
XVllI A SHORT ACCOUNT OP THE
would otherwise have been infalhbly lost. However,
as we must suppose that the doctrine which these gen-
tlemen have promulgated arose from humane motives,
and upon a conviction of its being well founded, we
must at least applaud their intention, though we cannot
approve their judgment. But if it were possible that
any man could be found capable of writing in defence
and support of the unfeeling doctrine, that mutilated
men are a burthen to the state, and that it is cheaper to
enlist men than to cure them, such a work would de-
serve to be reprobated, and the author's name to be
consigned to the detestation of posterity.
In 1779, Mr. Pott pubhshed his Remarks on that
kind of palsy of the limbs which is frequently found to
accompany a particular curvature of the spine. He in-
troduced his first treatise on this subject with doubts
and surmises, having just drawn the outline; but, find-
ing his opinion confirmed by experience, he with confi-
dence produced his further remarks on this disease, in
1783, in which he gives a complete description of the
complaint, so little understood before, that those wh©
suffered under it were consigned to their fate, which
usually led to inactivity, deformity, and death. In this
valuable tract he lays down a very accurate discrimina-
tion of this from every other species of paralysis, and
proposes a new and most efficacious method of stopping
its progress, and curing it.
This was the last of his literary productions: the
mode of cure which he recommends in it he afterwards
applied to diseases of the hip-joint, with considerable
Success. If his life had fortunately been prolonged, it
was his intention to pubhsh his opinions on this subject.
At the same time, I have, great reason to think he would
LIFE OF MR. POTT. XIX
iiave added an account of those very painful excres-
cences which are frequently the consequence of long-
neglected piles. He had been remarkably succes'^ful in
the treatment of this afllicting complaint, and thought
the disease itself not sufficiently understood, nor the
mode by which he succeeded commonly practised; but,
as it was not his custom to begin to write on any sub-
ject till he was prepared to finish it, it is to be lamented
that his ideas on these and some other important points
were not committed to paper. As Mr. Pott conceived
these subjects to be of so much importance, I cannot
pass them over in silence, though I much regret that
they have not been laid before the public in his compre-
hensive manner.''
The time now began to approach when Mr. Pott may
be said to have attained the summit of that eminence
which he owed to himself alone. Though unadorned
with any honorary distinction in the profession, he was
sought after and employed by persons in the first degreed
of rank and power; and though he solicited neither
honours nor favours for himself, he often successfully
employed his influence on behalf of others. He was
universally consulted; practitioners referred to him in
cases of uncommon difficulty and danger, as their last
resource; his extensive experience, and his ready appli-
cation of it, rendered that easy to him, which, to most
other men, would have been a painful pre-eminence.
The Royal College of Surgeons in Edinburgh were
not inattentive to his deserts. In 1 786 he received a
diploma, accompanied by a letter expressive of the sense
they entertained of them: the value of the honour was
"i vide Vol. n.
XX A SHOUT ACCOUNT OF THE
greatly enhanced by his being the first person on whom
they had thought proper to bestow it.*"
In the following year the Royal College of Surgeons
in Ireland presented him with their freedom, in a silver
box/
In July 1787 he resigned the office of Surgeon to St.
Bartholomew's hospital, after having served it, as he
used to say, man and boy, half a century. On the day
of his resignation, the annual meeting of the governors
was held, and they dined in the great room of the hospi-
tal: when he w^as about to retire, the Right Honourable
=(COPY.)
" SIR, Edinburifh, Aug. 1, 1786.
" It is with peculiar pleasure I obey the commands of the Royal College
of Surgeons in acquainting you, that they have this day unanimously elected
you an Honorary Fellow of the Royal College of Surgeons of Edinburgh, a
compliment which they think your very distinguished merit justly enti-
tied to.
" May I add, as an additional mark of the College's respect, that you are
the first Gentleman of the Faculty they have thought proper to bestow the
honour on.
" I have the honour to be, &c.
"THOMAS HAY, President."
f(COPY.)
" HONORARY DIPLOMA
" Voted to Fercivali. Pott, Esq. Sept. 9th, 1787, by the Royal College of Sur^
geons in Ireland.
" Whereas it has appeared to us, in full College duly assembled, that Per-
civall Pott, Esq. lias eminently distinguished himself in the science of sur-
gery; now, we being desirous to manifest our approbation of conspicuous
merit, do, by virtue of the powers vested in us by his majesty's royal charter,
by these presents, elect, constitute, and appoint, the said P. Pott an Hono-
rary Member of this College, with all the privileges, dignities, and immunities
thereunto annexed.
(Signed) « J. WHITEWAY, President."
LIFE OF MR. POTT. ^ XXI
Thomas Harley, president, proposed a health to Mr.
Pott, with many thanks for his long, able, and faithful
services to that house; which was received with reitera-
ted bursts of applause. Mr. Pott's usual readiness for-
sook him on this trying occasion: after repeatedly ris-
ing to thank the assembly for the compliment they had
paid him, he felt himself obliged to sit down in silence.
His resolution and presence of mind, though not easily
overcome, were not proof against the powerful emo-
tions excited by this public and unexpected testimony
of his having acted well, and filled an important station
to the advantage of mankind.
It is possible that some of the greatest blessings we
enjoy, may, by a fortuitous concatenation of events, tend
to shorten their own existence. Thus it seemed in the
case of Mr. Pott, whose remarkable temperance had in-
sured him so long a continuance of health and spirits,
that he was deceived in himself. Had he been subject
to some of the infirmities which usually attend people
of his age, as he must necessarily have paid more atten-
tion to his general health, his days might possibly have
been prolonged. Though he was free from any parti-
cular complaint, and his constitution was sound, still it
sustained the weight of more than threescore years and
ten! to this his mind, busy and cheerful as ever, would
not permit him to advert. It is painful to relate, that, in
the full possession of his faculties, with a frame of body
apparently calculated to last much longer, he fell a sa-
crifice to his own active disposition, and inattention to
the first attack of his disorder.
On Thursday, 11th December, 1788, he went, in
very severe weather, to visit a patient about twenty miles
from London: when he returned, he complained that
XXll A SHORT ACCOUNT OF THE
he had caught a cold. The next day he lay in bed, a
circumstance very uncommon to him; the following day,
thinking himself better, he would not submit to the re-
gimen which had been recommended, but went out as
usual; the day after (Sunday the 14th) the cold was re-
markably intense, and it being necessary to repeat the
visit in the country, I was happy to save him so incle-
ment a journey; but, at my return, was informed that
he had been a round of visits in town, and was just
got home, perceiving himself unable to complete his list.
A shivering soon seized hiui, and he went to bed; a fe-
ver succeeded, and before night he grew delirious. He
passed great part of the night in this state; the next
morning, on my asking how he found himself, after a short
apparent struggle for recollection, the words of his an-
swer precisely were: — "My mind has great propensity
"to aberration; and I find myself much inchned to
" talk nonsense, unless I studiously collect my thoughts,
" and fix them." — Through the whole of his illness,
during the intervals of reason, his observations on many
subjects were remarkably sensible and pointed; and he
seemed particularly attentive to correctness in his lan-
guage. The description of the pain he felt was anato-
mically exact. He did not appear to doubt of his reco-
very during several days, though the fever continued,
with unremitting violence, in opposition to the best me-
dical assistance, being attended with the most affectio-
nate assiduity, by the late Dr. Heberden, Sir Francis
Millman, and the late Dr. Austin. His head became
lather more clear as the disorder advanced, and he
seemed more sensible of his danger; on the seventh day
he observed, " My lamp is almost extinguished; I hope
•■ it has burned for the benefit of others." On the fol-
lowing day, the 22 d of December, he expired.
LIFE OF MR. POTT. XXlll
His remains were attended by many of his relations
and friends to Aldermary church in Bow-lane, where
they were deposited near those of his beloved mother.
On a marble tablet affixed to the wall is the following
inscription, by his son the Rev. Joseph Holden Pott,
A. M. Archdeacon of St. Alban's, &c.
In Memory
Of PERCIVALL POTT, Esq. F. R. S.
Surgeon of St. Bartholomew's Hospital during Forty-two Years,
Who departed this Life, December 22d, 1788, aged 75.
He was
Singularly eminent in his Profession,
J'o which he added many new Resources, and which he illustrated
With matchless Writings.
Let Posterity revolve the Sum of his Experience,
That the World may still enjoy the Benefit of his
Successful Practice.
He honoured the collective Wisdom of past Ages :
The Labours of the Ancients were familiar to him :
He scorned to teach a Science of which he had not traced the growth ;
He rose, therefore, from the Form to the Chair.
Learn, Reader, that the painful Scholar can alone become
The Faithful Teacher.
But his Studies had a double Issue :
Whilst he gathered the Knowledge of his Predecessors^
He perceived their Errors, and corrected them;
He discovered their Defects, and supplied them.
Original In Genius, prompt in Judgment, rapid in Decision,
He directed Knowledge to its proper Ends ;
But pursued them when the Aids of Information were exhausted ;
The last Steps, therefore, and great Improvements,
Were his own.
His Integrity is before his Judge ;
Without it, his Skill might have profited Mankind,
T*,ut could have claimed no Record within these Walls:
His private Virtues,
His signal Tenderness to his Family,
Completed an F.xample,
Amiable, Useful, Great,
XXIV A SHORT ACCOUNT OF THE
The genius of Mr. Pott, however assisted by art, was
certainly of the first order by nature, as appears by the
variety and perfection of his attainments. He was the
most eminent of his time as a writer, as a teacher, and
as a practitioner in surgery; and his merits in each of
these characters were most extensive. Possessed with
an enthusiastic love of excelling, without which genius
is inert, he was not contented with any kind of medi-
ocrity in himself
As an author, his language is correct, strong, and
animated. There are few instances, if any, of such
classical elegance, united with so much profound scien-
tifical acuteness. In his surgical inquiries he studiously
avoided reference to obscure and general principles; he
preferred reasoning by analogy and induction from esta-
blished facts; a method certainly more safe and more
accommodated to the present state of physiological
knowledge. He introduces anatomy and physiology,
whenever it is necessary, to illustrate and distinguish
diseases; but never confuses his reader with uncertain
hypothesis in pathology, founded on physiological prin-
ciples. He was of opinion, and it is the opinion of
Newton, that hypothesis has no place in any physical
science. To place the disease in a distinct point of
view; to demonstrate wherein it consisted, and the
changes which must be effected to remove it; to point
out the remedies which would most safely and certainly
produce those changes, were the objects to which he
directed his whole attention. His remedies always
strongly marked his intention; they were decided and
consistent; and he w^as the principal author of that sim-
plicity which distinguishes the present practice from
LIFE OF MR. POTT. XXV
that of our ancestors. With these views he apphed
himself to every part of the surgical art, and improved
both the pathology and cure of many diseases. His
treatment of fistulous sores, and his history and cure of
the caries of the corpora vertebrarum, were, perhaps,
his greatest works: but his improvements, as we have
seen, extended to many other subjects; and his re-
searches introduced such novelties in the practice of
surgery, that his life must ever be considered as a great
epoch in the history of that art.
As a teacher, he had acquired the faculty of speaking
readily, with great point and energy, of delivering the
most prolix and intricate sentences with incredible pers-
picuity and correctness, and of enforcing what he said
with a most harmonious and expressive elocution. He
allowed no excuse for defects in himself; he always
avowed that excellent maxim, —
-Cui lecta potenter erit res,
Nee facundia deseret hunc, nee lucidus ordo.
As a practitioner in surgery, we must apply to him
all the essential qualifications, sound judgment, cool de-
termination, and great manual dexterity. He had seen
much of practice, and what he had seen he had digest-
ed, by reading, writing, and lecturing on those sub-
jects.
In the transaction of business there was a freedom
and openness in his manner, which evidentiy arose from
a consciousness that the opinion which he delivered was
founded on experience. In every instance he shunned
affectation and singularity; and his conduct in all situ-
ations was an appeal to the good sense of mankind.
VOL. I. D
XXVI A SHORT ACCOUNT OF THE
Thus he acquired the universal confidence of the pro-
fession; and, without any accidental or external help,
he raised himself to the greatest dignity which man can
attain — the first rank in a liberal profession.
Domestic virtues make no great figure in history;
yet the domestic virtues of distinguished men should not
be forgotten, because they promote the cause of virtue;
besides, great and amiable quahties reflect lustre on
each other. The ambition, the industry, and enterprise
of Mr. Pott, did at no time interfere with the duties of
a husband and a father. Though his ready wit and
brilhant conversation, abounding with interesting anec-
dotes of his own observation, and with happy quotations
from modern and ancient authors, rendered him a con-
spicuous character in all parties, he was most happy,
and not less to be admired, in the circle of his family.
In their society, he spent much the greater part of his
leisure hours, and in such a manner as to be the object
of the utmost affection and veneration to a numerous
offspring of children and grand-children.
The person of Mr. Pott was elegant, though lower
than the middle size; his countenance animated and
expressive; his manners and deportment were graceful;
and his remarkable vigour and activity seemed unabated
by age.
The labours of the greatest part of his life were with-
out relaxation; — an increasing family required his ut-
most exertion. Of late years he had a villa at Neasden;
and in the autumn usually passed a month at Bath, or
at the sea-side. Thus, though he gathered, as he ex-
pressed it, some of the fruit of the garden which he had
planted as he went along, and always lived in a generous
LIFE OF MR, POTT. XXVU
and hospitable manner, at the same time bestowing on
four sons and four daughters a hberal and necessarily
expensive education, and applying large sums to their
establishment during his life-time, he left an ample pro-
vision for them at his decease. Among his papers was
found, what he had often mentioned, a small box, con-
taining a few pieces of money,* being the whole which
he ever received from the wreck of his father's fortune.
With this was deposited an exact account of every indi-
vidual fee which a long life of business had produced —
abundant evidence of well-spent time, and the indus-
trious application of abilities, to which the res angusta
domi, at the commencement, probably acted more pow-
erfully as an incentive than as an obstacle.
J. E.
Hanovei"- Square, January 1st, 1808.
* Under 51.
MATURE AKD COJSrSEQUEJSrCES
INJURIES
TO WHICH
THE HEAD IS LIABLE
EXTERNAL VIOLENCE.
SECT. I.
WOUNDS OF THE SCALP.
PREVIOUS to an account of such wounds and injuries of the
head as interest the scull, the brain, and its membranes, it may
not be amiss to take some small notice of those to which the scalp
is liable. Though this be called the common tegument of the
head, yet, from the variety of parts of which it is composed, from
their structure, connexions, and uses, injuries done to it by external
violence become of much more consequence than the same kind
of ills can prove when inflicted on the common teguments of the
rest of the body.
The covering, called the scalp, consists of the cutis, the mem-
brana adiposa, or cellularis, the expanded tendons of the frontal,
occipital, and temporal muscles, (forming a kind of aponeurosis,)
and the membrane which immediately covers the bones of the
scull, called therefore the pericranium.
This variety of parts, upon the infliction of wounds, blows, &c.
frequently occasions a variety of symptoms; which symptoms
ought by practitioners to be carefully and properly distinguished
from each other; not only because they often arise from the dis-
tinct and particular nature of the part injured, but because they
generally point out the most eifectual means of relief. If to these
considerations we add another, no less true and important, viz.
that there is and must be a constant communication, by means of
blood-vessels, between all the parts without and within the head,
it will appear, that injuries done to this part, though seemingly,
and at first sight, slight and trivial, may sometimes prove of the
greatest consequence.
I will not waste the reader's time, by entering into a detail of
3^ INJURIES OF THE HEAD
the method of treating common incised wounds; but proceed im-
mediately to those which, though the mischief be originally con-
fined to the mere scalp, yet are frequently very terrible to behold,
are often attended with alarming symptoms, and sometimes with
danger. These are what are called lacerated wounds, and those
made by puncture. The former may be reduced to two kinds,
viz. those in which the scalp, though torn, or unequally divided,
still keeps its natural situations, and is not stripped or separated
from the cranium to any considerable distance beyond the breadth
of the wound; and those, in which it is considerably detached from
the parts it ought to cover.
The first of these, if simple, and not combined with the symp-
toms or appearances of any other mischief, do not require any par-
ticular or different treatment from what the same kind of wounds
require on all other parts; but the latter (those in which the scalp
is separated and detached from the parts it ought to cover) are not
only, by the different methods in which they may be treated, fre-
quently capable of being cured with a considerable deal more or
less ease and expedition, but prove also sometimes matter of great
consequence to the health and well-being of the patient. Both
writers and practitioners differ much in their advice and conduct
on this subject. With some it is a practice immediately to remove
such portion of the scalp as is fairly and perfectly detached
from the parts underneath; with others, to attempt its preserva-
tion.
Each of these opinions can be considered, in a general sense
only, not as applicable to every individual case without distinction;
and taken in such general consideration, they cannot be both right.
It may therefore be worth while to inquire, what reasons each
party has to give for its opinion and conduct.
They who advise the removal affirm, that when a large por-
tion of the scalp has been perfectly and totally separated from
the parts it ought to cover, and that for some considerable space,
it will not again coalesce or unite with such parts; and therefore
that an attempt to procure such union, by replacing the separated
piece, will only protract the time of cure, by furnishing a lodg-
ment for matter and sloughs, which matter and sloughs must pre-
vent the thing intended. That in case of large wounds, or of
PROM EXTERNAL VIOLENCE. 33
those produced by great force, as we cannot by any means be
absolutely certain that no mischief is done to the parts under the
cranium, the replacing the lacerated scalp may not only prevent
our immediate inquiry into the nature of such mischief, but may
conceal and hide (at least for a time) such future appearances as
might furnish indications to direct a surgeon's conduct.
They who advise the preservation of the separated scalp,^ do
it upon a supposition, that it will in general unite again; that if
it do, the patient may thereby be spared a great deal of pain, save
much time, and sustain much less deformity; that with regard to
the immediate inquiry into the state of the cranium, it may be
made before the scalp is replaced; that if there be no present
symptoms which indicate injury done to the parts underneath, it
would be absurd to act merely upon the presumption that there
may be some in future; that it will be more proper and vindicable
to do what is right at first, or according to the present circum-
stance, and to attend to what may happen or occur hereafter,
when such occurrences have happened; and that the formation of
matter and sloughs, under the detached and replaced portion, will
not, in general, under proper management, prevent its re-union.
It is to be presumed, that every practitioner wishes to cure his
patients as soon as he can, by the least painful means, and in
such manner as shall be productive of the least possible deformity
or defect; taking care at the same time, not to be inattentive to
any evil which may arise, nor to omit or neglect doing whatever
maybe necessary during such cure.
Upon this principle, I make no scruple of declaring it as my
opinion, that the preservation of the scalp ought always to be at-
tempted, unless it be so torn as to be absolutely spoiled, or there
are manifest present symptoms of other mischief. This kind of
wound is sometimes very terrible to look upon, and they who have
not been accustomed to see it, may be inclined to think there is
no remedy but excision: but I have so often made the experiment
of endeavouring to preserve the torn piece, and have so oft§n
succeeded, that I would recommend it as a thing always to be at- ^
* I presume I need not observe, that when I say separated, I mean only
with regard to the inferior surface of such piece, and that it is still contiguous
with some part of the skin.
VOL. I. E
34 INJURIES OF THE HEAD
tempted, even though a part of the cranium shoukl be perfectly
bare, unless the two circumstances already mentioned render it
improper or impracticable. The removal of it necessarily pro-
duces a larger sore, which must require a good deal of time to
heal, and must leave a considerable deformity: the preservation of
it prevents both.
Therefore, when such case occurs, let the surgeon be particu-
larly careful to examine, whether there be any appearances, or
symptoms, of any other kind of mischief beside what the scalp
has sustained; and if there be neither, let him make the torn piece
clean from all dirt, or foreign bodies, and restore it quickly, and
as perfectly as he can, to its natural situation*''
^ The distance from the place where the accident happens, and other
causes, frequently prevent the surgeon from examining the wound, until a
considerable time has elapsed, when, without any application having been
made to it, the surface of the torn scalp, and the parts which adhere to the
cranium, are become dry, and are apparently not in a state to lieal by tlie
first intention ; or some dressings may have been applied, wliicli, by the
nature of them, and by keeping the parts separate, add to the indisposition
to unite. In either of these cases, notwithstanding many hours may have in-
tervened, this excellent idea of saving the scalp need not be abandoned ; on
the contrary, after the wound has been thoroughly washed and cleansed, the
surfaces of it should be lightly scai-ified with the point of a lancet ; when,
being thus refreshed, and yielding a small effusion of blood, the immediate
union between them will probably take place, provided they are brought
into contact, and retained as Mr. Pott directs. — To explain my meaning, I
will select the following instance : A gentleman, about twenty years old,
thrown from his horse, and entangled in the stirrup, received a kick on the
forehead. As he was at a great distance from London, I did not see him till
forty hours after the accident : he had been, and still continued, in a state of
insensibility : the horse's shoe had struck him on the edge of the orbit, and
had torn the eye-brow and nearly one half of the covering of the forehead,
which was raised, and formed a flap. The wound, which was very large,
had been filled soon after the accident, with lint : it immediately occurreii
to me, that, if it were suffered to heal in this situation, the consequent de-
formity must be deplorable. I therefore removed the dressings, and found
the OS frontis denuded in two places : there was no fracture, except of a
small portion of bone, which had been broken off from the edge of the orbit,
and his symptoms were those of general concussion. I conceived it would
be right to endeavour to procure an union of the separated parts, though
from the length of time since they had been divided, and from the dressings,
which had left the fibres dry and constringed, they appeared very ill dis-
posed to unite. However, after having got rid of the remainder of the lint.
PROM EXTERNAL VIOLENCE. 35
The manner in which it is to be there maintained, must a good
deal depend upon the particular circumstances of each individual
case, and therefore must be left to the surgeon, who will make
use of plaster, bandage, and suture, together or separately, as
and made it perfectly clean with warm water, I scarified the whole internal
surface of tiie detached scalp, and the parts of the muscle which still adhered
to the bone, which his absence of perception enabled me to perform freely.
I then brought them into contact, and retained them in that situation by the
dry suture. I had the satisfaction to find them unite by the first intention,
making a simple line nearly down the middle of the forehead. By proper
treatment he soon regained his senses ; and a small exfoliation from the edge
of the orbit, at the bottom of the wound, was the only circumstance which
for some time retarded the perfect cure.
I will mention another case In which very different treatment, but equally
wrong, had taken place before I saw the patient : —
A man sitting on the shafts of a loaded waggon fell down in a fit : as he lay
On his face, the wheel passed over the right side of the head, tore off the
whole of the scalp from the parietal and temporal bones, and from part of the
frontal bone. The integuments also which covered the under part of the
orbit and cheek were much torn and bruised : in short, a more completely
mangled and shocking object can scarcely be imagined.
The whole of this large wound I found covered with a soft greas)' poultice.
On taking it off, though the wound had been in some measure washed and
cleansed, the remaining mud mixed with blood presented the appearance of
a dirty quagmire, in which the wounded portions were loose and floating,
but still retained some connexion with the neighbouring parts. The poultice
had been applied all night, and part of the day. Ii is evident at first sight
that the consequence of the continuance of such application must be the
sloughing and destruction of all these parts ; and if life were preserved, the
poor sufferer must remain a miserable object. I therefore ordered it to be
well cleansed in every part with warm water, the doing of which completely
was not an easy task. When this was thoroughly accomplished, I scarified
freely every part of the wound over the whole surface of the parts which
still adhered to the bones as well as the inside of the torn portions of scalp,
which, though so ragged, so torn to shreds and tatters that I thought it im-
possible that they should all unite, I would not suffer to be I'emoved, but
gave them all a chance, thinking that those parts which should die from want
of circulation, might easily be taken away at some future opportunity. I
then brought all the p.arts as nearly as possible into their natural situation,
and retained them by means of ligatures, strips of sticking plaster, and
bandages liglitly applied.
Some blood was taken from the arm, which, with open bowels and a low
diet, prevented considerable inflammation from coming on. From day to
day such strips of sticking plaster as were loose were removed, and others
36 INJURIES OP THE HEAD
he shall find them most convenient, and best fitted to the pur*^-
pose.
I am aware that the very mention of a suture in a wound of
the scalp, particularly a lacerated one, will startle some of my
readers, who have been taught that it is always wrong in both;
I know that this is the general doctrine, but I know also, that al-
though it be sometimes true, yet, if it be implicitly adhered to, it
will prevent a practitioner now and then from receiving very use-
ful assistance. A stitch, made with a slip-knot, will sometimes
hold the divided parts in such situation, as will greatly expedite a
cure: in many cases a very short time will answer the end, and
the thread may be removed as soon as ever the purpose is accom-
plished, or the suture becomes either improper or useless.
In some cases this will be all that is required; the loosened
scalp will unite with the parts from which it was torn and sepa-
rated, and there will be no other sore, than what arises from the
impracticability of bringing the lips of the wound into smooth and
immediate contact, the scar of which sore must be small in pro-
portion.
On the other hand, it sometimes happens that such perfect re-
union is not to be obtained; in which case, matter will be formed
and collected in those places where the parts do not coalesce: but
this does not necessarily make any difference, either in the gene-
ral intention, or in the event: this matter may easily be discharged,
by one or two small openings made with a lancet; the head will
applied. In the progress of a few days I was agreeably surprised to see that
in general an union liad taken place, except on the sides of some of the
smaller portions of the detached scalp, and the extremities of others which
remained black and lifeless, and which of course were taken away; and
particularly there was a small portion under the eye, which, being dead for
want of a nourisliing vessel, sloughed and came away, and threatened a con-
siderable disfigurement. The loss however was greatly remedied by bring-
ing the neighbouring parts as nearly together as possible. In no great
length of time the whole wound was healed, when all those who had witness-
ed the accident, and observed its progi-ess toward amendment, as well as my-
self, were astonished at the little scar or deformity left from so extensive and
complicated a wound.
I may add, that the man, before the accident, had been reckoned hand-
some, and the front view of his face afterward still retained its comely ap-
pearance. E.
PROM EXTERNAL VIOLENCE. 37
&till preserve its natural covering; and the cure will be very little
retarded by a few small abscesses.
I must desire not to be misunderstood: I do not mean to say,
that it must be always and invariably right, to return the loosened
scalp, and to endeavour to procure its immediate re-union, or that
such attempt will always succeed; I only mean to signify, that it
is my opinion, (and that founded on experience,) that the mere se-
paraiion or detachment of the scalp, to however large an extent, is
not a good and sufficient reason for cutting off any part of it in
cases where no other mischief seems to have been done, in which
the cranium is uninjured, and the parts within it unhurt; and, that
the attempt to procure a re-union with the parts from which it was
separated, though it will sometimes fail, yet will most frequently
succeed; and is always worth making; as such experiment, pro-
perly made, can never be attended with any real inconveniences.
In some cases, the whole separated piece will ^i(as I have said
before) unite perfectly, and give little or no trouble, especially in
young and healthy persons; in some, the union will take place in
some parts, and not in others; and consequently matter will be
formed, and require to be discharged, perhaps at several different
points; and in some particular cases, circumstances, and habits,
there will be no union at all: the torn cellular membrane, or the
naked aponeurosis, will inflame and become sloughy, a considera-
ble quantity of matter will be collected, and perhaps the cranium
will be denuded: but even in this state of things, which does not
very often happen where proper care has been taken, and is almost
the worst which can happen in the case of mere simple laceration
and detachment, I say, even in this, if the surgeon will not be too
soon, nor too much alarmed, nor in a hurrry to cut, he will often
find the cure much more feasible than he may at first imagine: let
him take care to keep the inflammation under by proper means;
let him have patience till the matter is fairly and fully formed, and
the sloughs perfectly separated; and when this is accomplished,
let him make a proper number of dependent openings for the dis-
charge of them; and let him by bandage, and other proper ma-
nagement, keep the parts in constant contact with each other, and
he will often find, that, although he was foiled in his first intention,
of procuring immediate union, yet he will frequently succeed in
$8
INJURIES OF THE HEAD
this his second; he will still save the scalp, shorten the cure, and
prevent the great deformity arising (particularly to women) not
only from the scar, but from the total loss of hair.
I have said, that this union may often be procured, even though
the cranium should have been perfectly denuded by the accident;
and it is true, not only though it should have been stripped of its
pericranium at first, but even if that pericranium should have be-
come sloughy and cast off, as I have often seen.
Exfoliation from a cranium laid bare by external violence, and
to which no other injury has been done than merely stripping it of
its covering, is a circumstance which would not so often happen,
if it were not taken for granted that it must be, and the bone treat-'
ed according to such expectation: the soft open texture of the bones
of children and young people will frequently furnish an incarna-
tion, which will cover their surface, and render exfoliation quite
unnecessary; and even in those of mature age, and in whom the
bones are still harder, exfoliation is full as often the effect of art,
as the intention of nature, and produced by a method of dressing,
calculated to accomplish such end, under a supposition of its being
necessary. Sometimes indeed it happens that a small scale will
necessarily separate, and the sore cannot be perfectly healed till
such separation has been made: but this kind of exfoliation will
be very small and thin, in proportion to that produced by art,
which is, that produced by dressing the surface of the bare bone
with spirituous tinctures, &c.; and when a wound on the head,
with a sound uninjured bone, denuded by accident, shews a dis-
position to heal without exfoliation, it never can be right to coun-
teract nature, and oblige her to do that she is not inclined to, and
which she would otherwise accomplish better.
If the scalp be detached by such means, or with such force of
instrument, that the scull or parts within it have suffered, then
tlie immediate union of the skin becomes impracticable, and it
would be highly injudicious to attempt it: our attention then must
be paid to the greater evil; it then becomes another kind of case,
and all that need be said of it in this place is, that although such
mischief do generally require the removal of some part, yet even in
this situation, no more of it should be cut off than what will be ne-
cessary for the detection and proper treatment of such mischief.
FROM EXTERNAX. VIOLENCE. 39
In short, whether considered as skin, or as the seat of the hair, it
ought never to be removed wantonly, or without absolute neces-
sity.
Small wounds, that is, such as are made by instruments or bo-
dies which pierce or puncture rather than cut, are in general more
apt to become inflamed, and to give trouble, than those which are
larger; and in this part particularly are sometimes attended with
so high inflammation and with suqh symptoms, as alarm both pa-
tient and surgeon.
The parts capable of being hurt by such kind of wound, are
the skin, the tela cellulosa, the expanded tendons of the muscles
of the scalp, and the pericranium.
If the wound be no deeper than the cellular membrane, and has
not reached the aponeurosis or pericranium, the inflammation and
tumour affect the whole head and face, the skin of which wears a
yellowish cast, and is sometimes thick set with small blisters, con-
taining the same coloured serum; it receives the impression of the
fingers, and becomes pale for a moment, but returns immediately
to its inflamed colour; it is not very painful to the touch, and the
eye-lids and ears are always comprehended in the tumefaction,
the former of which are sometimes so distended, as to be closed;
a feverish heat and thirst generally accompany it; the patient is
restless, has a quick pulse, and most commonly a nausea, and in-
clination to vomit.
This accident generally happens to persons of bilious habit, and
is indeed an inflammation of the erysipelatous kind; it is somewhat
alarming to look at, but it is not often attended with danger. The
wound does indeed neither look well, nor yield a kindly discharge,
while the fever continues, but still it has nothing threatening in
its appearance, none of that look which bespeaks internal mis-
chief; the scalp continues to adhere firmly to the scull, and the
patient does not complain of that tensive pain, nor is afflicted
with that fatiguing restlessness which generally attends mischief
underneath the cranium.
Phlebotomy, lenient purges, and the use of the common febri-
fuge medicines, particularly those of the neutral kind, generally
remove it in a short time. When the inflammation is gone off",
it leaves on the skin a yellowish tint, and a dry scurf; which con-
40 INJURIES OF THE HEAD
tinue until perspiration carries them away, and upon the disap-
pearance of the disease, the wound immediately recovers a healthy
aspect, and soon heals without any further trouble.
Wounds and contusions of the head, which affect the brain and
its membranes, are also subject to an erysipelatous kind of swell-
ing and inflammation; but it is very different, both in its charac-
ter and consequences, from the preceding.
In this (which is one of the effects of inflammation of the me-
ninges) the febrile symptoms are much higher, the pulse harder
and more frequent, the anxiety and restlessness extremely fatiguing,
the pain in the head intense; and as this kind of appearance is,
in these circumstances, most frequently the immediate precursor
of matter forming between the scull and dura mater, it is general-
ly attended with irregular shiverings, which are not followed by a
critical sweat, nor afford any relief to the patient. To which it
may be added, that in the former case the erysipelas generally
appears within the first three or four days; whereas in the latter,
it seldom comes on till several days after the accident, when the
symptomatic fever is got to some height. In the simple erysipe-
las, although the wound be crude and undigested, yet it has no
other mark of mischief; the pericranium adheres firmly to the
scull, and, upon the cessation of the fever, all appearances become
immediately favourable. In that which accompanies injury done
to the parts underneath, the wound not only has a spongy, glassy,
unhealthy aspect, but the pericranium in its neighbourhood sepa-
rates spontaneously from the bone, and quits all cohesion with it.
In short, one is an accident, proceeding from a bilious habit, and
not indicating any mischief beyond itself; the other is a symptom,
or a part of a disease, which is occasioned by injury done to the
membranes of the brain; one portends little or no ill to the pa-
tient, and almost always ends well; the other implies great haz-
ard, and most commonly ends fatally. It fs therefore hardly ne-
cessary to say, that it behoves every practitioner to be careful in
distinguishing them from each other.
If the wound be a small one, and has passed through the tela
cellulosa, to the aponeurosis, and pericranium, it is sometimes at-
tended with very disagreeable, and even very alarming symptoms,
FROM EXTERNAL VIOLENCE. 41
Ijut which arise from a different cause, and are very distinguish-
able from what has been yet mentioned.
In this the inflamed scalp does not rise into that degree of tume-
faction, as in the erysipelas; neither does it pit, or retain the im-
pression of the fingers of an examiner: it is of a deep red colour,
unmixed with the yellow tint of the erysipelas: it appears tense,
and is extremely painful to the touch. As it is not an affection of
the tela cellulosa, and as the ears and the eye-lids are not covered
by the parts in which the wound is inflicted, they are seldom, if
ever, comprehended in the tumour, though they may partake of
the general inflammation of the skin: it is generally attended with
acute pain in the head, and such a degree, of fever as prevents
sleep, and sometimes brings on a delirium."
A patient in these circumstances will admit more free evacua-
tions by phlebotomy, than one labouring under an erysipelas: the
use of warm fomentation is required in both, in order to keep the
skin clean and perspirable; but an emollient cataplasm, which is
generally forbid in the former, may in this latter case be used to
great advantage.
When the symptoms are not very pressing, nor the habit very
inflammable, this method will prove sufficient: but it sometimes
happens, that the scalp is so tense, the pain so great, and the
symptomatic fever so high, that by waiting for the slow effect of
such means, the patient runs a risque from the continuance of
the fever; or else the injured aponeurosis and pericranium be-
coming sloughy, produce an abscess, and render the case both
tedious and troublesome. A division of the wounded part by a
simple incision down to the bone, about half an inch or an inch
'In the last lecture which Mr. Pott gave on this subject, he candidly ob-
served, that he found he had drawn the line of distinction between those
wounds by whicli the tela cellulosa alone is hurt, and those which penetrate
through and puncture the aponeurosis and pericranium, too decidedly, and
said he was convinced, that the different symptoms which he had supposed
to follow the wound of this or that part, often arose from the constitution
and habit of the person woiuided, rather than from the nature of the accident,
and that the consequences could not always be deducible from the particu-
lar part which had received the injury ; for that, since be had written on the
subject, he had remarked the s^me symptoms indiscriminately arising from
either kind of wound. E.
VOL. I. P
4S INJURIES Of THE HEAD
in length, will most commonly remove all the bad symptoms, anc?
if it be done in time, will render every thing else unnecessary.
The injuries to which the scalp is liable from contusion, or the
appearances produced in it by such general cause, may for method-
sake be divided into two classes, viz. those in which the mischief
is confined merely to the scalp, and those in which other parts are
interested.
The former, which only comes under our present consideration,
is not indeed of importance, considered abstractedly. The tu-
mour attending it is either very easily dissipated, or the extrava-
sated blood causing it, is easily got rid of by a small opening. I
should not therefore have thought it of such consequence, as to be ,
worth mentioning in this place, bad it not been for an accidental
circumstance, which sometimes attends it, and renders it liable to
be very much mistaken.
When the scalp receives a very smart blow, it often happens
that a quantity of extravasated blood immediately forms a tumour,
easily distinguishable from all others, and generally very easily
cured. But it also sometimes happens, that this kind of tumour
produces to the fingers of an unadvised or inattentive examiner, a
sensation, so like to that of a fracture, with depression of the cra-
nium, as may be easily mistaken. Now, if upon such supposi-
tion, a surgeon immediately removes the tumid scalp, he may
give his patient a great deal of unnecessary pain, and for that
reason run some risque of his own character.
The touch is, in this case, so liable to deception, that recourse
should always be had to other circumstances and symptoms, be-
fore an opinion be given.
If a person, with such tumour occasioned by a blow, and at-
tended with such appearances and feel, have any complaint, which
seems to be the effect of pressure made on the brain and nerves,
or of any mischief done to the parts within the cranium, the divi-
sion or removal of the scalp, in order to inquire into the state of
the scull, is right and necessary; but if there be no such general
symptoms, and the patient be in every respect perfectly well, the
mere feel of something like a fracture will not authorise or vindi-
cate such operation, since it will often be found, that such sensa-
tion is a deception, and that when the extravasated fluid is
PROM EXTERNAL VIOLENCE. 43
removed, or dissipated, the cranium is perfectly sound and un-
injured.
The second kind of tumour attending the contused scalp, viz.
ihat which arises from injury done to the cranium, and parts with-
in, does so absolutely proceed from, and depend upon such injury,
as not to fall under our consideration iii this place at all, but will
be considered at large when we come to speak of the mischiefs
done to the scull and brain by collision, or contusion.
From what has been said it appears, that the scalp, taken in a
general sense, is, vi'hen wounded or bruised, liable to be affected
with four kinds of tumour, each of which has a distinct cause, and
requires, or permits, a different method of treatment.
The first does not imply any injury done to the parts within
the scull, requires no operation, and almost always is cured by
general remedies.
The second, or tliat which is caused by the spontaneous sepa-
ration of the pericranium from the scull, in consequence of inter-
nal mischief, is not at first attended with very pressing symptoms;
but whoever has observed their progress, and attended to their
event, must know what fatal and frequently irresistible evil it is
the forerunner of, nothing less than the inflammation and putre-
faction of the membranes of the brain, and the formation of mat-
ter between them and the scull; and that it is a case which, of all
others, will least admit delay.
The third, though it sometimes gives way to free evacuation,
and lenient external applications, yet is sometimes also attended
with symptoms which are too pressing to wait the effect of such
remedies, and is capable of being immediately relieved by a divi-
sion of the inflamed and irritated parts; whereas the same incision,
made into the first kind of tumefaction, would most probably ex-
asperate the disease, and heighten the symptoms.
The fourth, consisting of extravasated blood, seldom requires
any chirurgic operation; time, and the use of the common discu-
tient applications,d almost always dissipate Jt; and it only becomes
of consequence by the possibility of its being misunderstood and
mistreated.
^ Among which I know of none equal to a solution of crude fal almon. in
vinegar and water, or spt. vin.
44 * INJURIES OF THE HEAD
SECT. II.
EFFECTS OF CONTUSION ON THE DURA MATER, AND PARTS WITHIN
THE SCULL.
In order fo understand rightly, and to have a clear idea of this
kind of injury, it is necessary to recollect, that the vessels of the
pericranium, those of the diploe, or medullary substance between
the two tables of some parts of the cranium, and those of the
dura mater within it, do all constantly and freely comrtaunicate
with each other; and that this communication is carried on by
means of innumerable foramina, found in all parts of both sur-
faces of the scull, as well as at the sutures; that upon the freedom
of this communication depends the healthy and sound state of all
the parts concerned in it; and that from the interruption or de-
struction of this proceed most of the symptoms attending violent
contusions of the head, extravasations of fluid between the cranium
and dura mater, inflammations of the said membrane, and simple
undepressed fracture of the scull.
The pericranium is so firmly attached to the outer surface of
the scull, as not to be separable from it without considerable vio-
lence; and when such violent separation is made in a living sub-
ject (especially if young) the cranium is always seen to bleed
freely, from an infinite number of small foramina. The dura
mater, which is a firm strong membrane, is almost as intimately
attached to the inside of the scull, as the pericranium is to the out-
side, and by the same means, viz. by vessels; and by these means
a constant circulation and communication are preserved and main-
tained between the two membranes and the bones dividing them.
This, all the appfjarances which attend the scalping a living per-
son, or the separation of the scull from the dura mater of a dead
one, (especially if such person died apoplectic, or was hanged,)
prove beyond all doubt : in the former, the blood will (as I have
already observed) be seen issuing from every point of the surface
of the cranium; in the latter, not only a considerable degree of
force will be found necessary to detach the sawed bone from the
FROM EXTERNAL VIOLENCE. 45
subjacent membrane, but when it is removed, a great number of
bloody points wili be seen all over the surface of the laUer; which
points, if wiped clean, do immediately become bloody again, being
only the extremities of broken vessels. These vessels are largest
at, and about the sutures, at which places the adhesion is the
strongest, and the haemorrhage upon separation the greatest.
It has been thought by many, that the dura mater was attached
to the scull only at the sutures; that in all other parts it was loose
and unconnected with it; and that it constantly enjoyed or per-
formed an oscillatory kind of motion, and was alternately elevated
and depressed. This idea and opinion were borrowed from the
appearance which the dura mater makes in a living subject after
a portion of the scull has been removed: but although it has been
inculcated by writers of great eminence, yet it has no foundation
in truth or nature, and has misled many practitioners in their
opinions, not only of the structure and disposition of this mem-
brane, but in their idea of its diseases.
The dura mater performs on the internal surface of the bones of
the cranium, the office of periosteum, in the same manner as the
pericranium does on the external; (at least they have no other:)
to this it is so firmly and so generally attached, as to be incapable
of any, even the smallest degree of motion. The alternate eleva-
tion and subsidence of it, which are observable when any portion
of it is laid bare, are owing to a very different cause from any
power in itself; neither is, nor can ever be performed, until a
piece of the cranium has been forcibly taken away; and conse-
quently cannot possibly be natural, or necessary.
By blows, falls, and other shocks, some of the larger of tliose
vessels which carry on this communication between the dura mater
and the scull are broken, and a quantity of blood is shed upon the
surface of that membrane. This is one species of bloody extrava-
sation, and indeed the only one which can be formed between the
scull and dura mater. If the broken vessels be few, and the quan-
tity of blood which is shed be small, the symptoms are generally
slight, and by proper treatment disappear. When they are large,
or numerous, or the quantity of extravasated fluid considerable,
the symptoms are generally urgent in proportion; but whether
they be slight or considerable, whether immediately alarming or
46 INJURIES OF THE HEAI>
not, they are always, and uniformly, such as indicate pressure
made on the brain and nerves, viz. stupidity, drowsiness, diminu-
tion or loss of sense, speech, and voluntary motion.
This every practitioner knows to be one frequent consequence
of blows on the head. But it also often happens, from the same
kind of violence, that some of the small vessels, which carry on
the circulation between the pericranium, scull, and dura mater,
are so damaged, as not to be able properly to execute that office,
although there be none so broken as to cause an actual effusion of
blood.
Smart and severe strokes on the middle part of the bones, at a
distance from the sutures, are most frequently followed by this
kind of mischief: the coats of the small vessels, which sustain
the injury, inflame and become sloughy, and, in consequence of
such alteration in them, the pericranium separates from the out-
side of that part of the bone which received the blow, and the
dura mater from the inside; the latter of which membranes, soon
after such inflammation, becomes sloughy also, and furnishes
matter; which matter being collected between the said membrane
and the cranium, and having no natural outlet whereby to escape,
or be discharged, brings on a train of very terrible symptoms, and
is a very frequent cause of destruction.^ The effect of this kind
of violence is frequently confined to the vessels connecting the
dura mater to the cranium, in which case the matter is external to
the said membrane; but it sometimes happens, that, by the force
either of the stroke or of the concussion, the vessels which pass
between and connect the two meninges are injured in the same
manner; in which case, the matter formed in consequence of such
violence is found on the surface of the brain, or between the pia
and dura mater, as well as on the surface of the latter; or perhaps
in all these three situations at the same time.
« Comment le perlcrane a-l-il pu ainsi se detacher de I'os dans le circon-
ference du coup ? ne seroit ce point par I'ebranlement ou le tremoussement
de toutes les parties integrantes du crane ? Si c'est en consequence d'un
tremoussement pareil que nombre de filets qui attachent le perici'ane au
crane se sont detaches, par la meme raison, plusieurs des filets qui attachent
la dure mere au crane out du se romprv" aussi : d'oii s'en suivit un erysipele,
qu'occaslon suppuration, ou plutot pourriture.
Le DsAy.
E*ROM EXTERNAL VIOLENCE. 41
The difference of this kind of disease, from either an extravasa-
tion of blood, or a commotion of the medullary parts of the brain,
is great and obvious. All the complaints produced by extravasa-
tion are (as I have already said) such as proceed from pressure
made on the brain and nerves, and obstruction to the circulation
of the blood through the former; stupidity, loss of sense, and
voluntary motion, laborious and obstructed pulse and respiration,
&c. and (which is of importance to remark) if the effusion be at
all considerable, these symptoms appear immediately, or very soon
after the accident.
The symptoms attending an inflamed or sloughy state of the
membranes, in consequence of external violence,^ are very dif-
ferent; they are all of the febrile kind, and never, at first, imply
any unnatural pressure; such are, pain in the head, restlessness,
want of sleep, frequent and hard pulse, hot and dry skin, flushed
countenance, inflamed eyes, nausea, vomiting, rigor; and, toward
the end, convulsion and delirium. And none of these appear at
first, that is, immediately after the accident ; seldom' mitil some
days are past.^
One set or class of symptoms are produced by an estravasated
fluid, making such pressure on the brain and origin of the nerves,
as to impair or abolish voluntary motion and the senses; the other
^ The diiference between these two effects of external violence, was very
well understood by Berengarius Carpensis, a most excellent writer on this
subject, who says, " Interdum eliam acontusione non rumpitur ahqua vena,
" sed rumpnntur ligamenta ilia durse matris ; a qulbus resudat aliquid : hisce
" vero nisi succuratur, accidunt sjeva accidentia, et mors."
Paulus ^T,gineta has also very particularly distins^uished between that de-
gree of contusion, wliich affects only the outer table of the scull, and that
which injures the dura mater. "Porro contusionis hujus duse existunt dif-
" ferentire : vel enim calva per totam ipsius crassitiem contunditur, ut fre-
"quenter etiam cerebri membrana abscessu occupetur; vel, &c."
g " Nulla autem haruni contusionum aspectu dignosci potest ; qualis nenipe,
" quantave sit. Non protlnus ab ictu malum se videndima praibet."
IltPPOCRATES.
"Sed accidentia quje sequuntur ad prrcdiclam conlusionera, inter commis-
"suras, non sunt per contusionem tanlum ; sed sunt pi'v pnlrefaclioiiem pan-
"niadi Ixsi, et cum venit ad certam quantitatem determinatam incipit febris,
" et alia accidentia : et tandem seqnitur mors, nisi cito succuratur."
Jacob cs Behexgauius Cabpetssis.
48 INJURIES OF THE UEAli
is caused by the inflamed or putrid state of the membranes cover-
ing the brain, and seldom affects the organs of sense, until the lat-
ter end of the disease, that is, until a considerable quantity of mat-
ter is formed, which matter must press like any other fluid.
I am very sensible that it is a generally-received opinion, that
blood shed from its vessels, ainl remaining confined in one place,
will become pus; and that the matter found on the surface of the
dura mater, towards the end of these cases, was originally extra-
vasated blood. I apprehend both these positions to be false. That
pure blood shed from its vessels, by means of external violence,
and kept from the air, will not turn to, or become matter, is
(I think) proved incontestibly by every day's experience, in many
instances, in aneurisms by puncture, in retained menses by im-
perforate vaginae, and in all ecchymoses. True pus cannot be
made from blood merely, as may be known from the manner in
which all abscesses are formed, and from every circumstance at-
tending suppuration; and that the matter found on the surface of
the dura mater, after great contusions of the head, never was
mere blood, I am as certain as observation and experience can
make me.
Some of the French writers have indeed divided the symptoms
of what they call a contusion of the head, into two kinds, and
have named them primitive or original symptoms, and secondary
or consequential ones: among the former, they rank immediate
loss of sense, haemorrhage, involuntary discharge of urine and
faeces, great propensity to sleep, &c.; among the latter they reckon
fever, delirium, rigor, convulsion, &c. One kind they impute to
the mere extravasation of blood, the other to its putrefaction.
This account, though ingenious and specious, is not founded on
fact. It is true, that the two kinds of symptoms are very distinct
from each other, as well in their nature, as in their time and man-
ner of access, and so far the remark is true; but from all the ob-
servation and examination which I have been able to make, both
on the living and on the dead, they appear to me to proceed from
very different causes. That both these kinds of symptoms do now
and then concur in the same patient, is beyond all doubt; and
that the case is thereby rendered complex, and more difficult to
jje judged of; but this does not constantly happen; and even when
FROM EXTERNAL VIOLENCE. 49
it does, I cannot help thinking, that there are generally such dis-
tinguishing characteristic marks of each, as may prove the truth
of what I have asserted.
In order to explain my meaning as clearly as I can, I will con-
sider the inflammatory effect of contusion by itself, and indepen-
dent of every other complaint or injury, which may accidentally
be joined with it.
If there be neither fissure nor fracture of the scull, nor extra-
vasation, nor commotion underneath it, and the scalp be neither
considerably bruised nor wounded, the mischief is seldom disco-
vered or attended to for some few day£ The first attack is ge-
nerally by pain in the part which received the blow. This pain,
though beginning in that point, is soon extended all over the
head, and is attended with a languor, or dejection of strength and
spirits, which are soon followed by a nausea, and inclination to
vomit, a vertigo or giddiness, a quick and hard pulse, and an in-
capacity of sleeping, at least quietly. A day or two after this
attack, if no means preventative of inflammation are used, the
part stricken generally swells, and becomes puffy and tender, but
not painful; neither does the tumour rise to any considerable
height, or spread to any great extent. If this tumid part of the
scalp be now divided, the pericranium will be found of a darkish
hue, and either quite detached, or very easy separable from the
scull, between which and it will be found a small quantity of a
dark-coloured ichor.
If the disorder has made such progress, that the pericranium is
quite separated and detached from the scull, the latter wall even
now be found to be somewhat altered in colour from a sound
healthy bone. Of this alteration it not very easy to convey an
idea by words, but it is a very visible one, and what some very
able writers have noticed."*
'' Among these Fallopius particularly: " Inspiciatis diligenter os detectum ;
" quod OS, quando est in natura sua, est coloris subrubri, non caiididi pror-
" sus, nee nibri prorsiis, sed est veluti color mistus ex albo declinans ad rubi-
" cundura, vit si multo lacte, aut alio colore candido, poneres pavum sanguinis
" vel allerius rei rubra:. Sed si videritis inseqiialitatem coloris in ipso osse de-
" tecto, ita ud adsiiit veluti puncta coleris albi, et aridi ossis, quae aridae par-
" ticulze alicniando niajores sunt, aliquando minores, &c. sciatis quod os sit
■" contusum." Failopibs.
VOL. I. &
50 INJURIES OF THE HEAD
From this time the symptoms generally advance more hastily
an^cl more apparently; the fever increases, the skin becomes hotter,
the pulse quicker and harder, the sleep more disturbed, the anxiety
and restlessness more fatiguing, and to these are generally added
irregular rigors, which are not followed by any critical sweat, and
which, instead of relieving the patient, add considerably to his
sufferings. If the scalp has not been divided or removed, until
the symptoms are thus far advanced, the alteration of the colour
of the bone will be found to be more remarkable; it will be found
to be whiter and more dry than a healthy one, or, as Fallopius
has very justly observed, it will be found to be more like a dead
bone: the sanies, or fluid, between it and the pericranium will
also, in this state, be found to be more in quantity, and the said
membrane will have a more livid diseased aspect.
In this state of matters, if the dura mater be denuded, it will be
found to be detached from the inside of the cranium, to have lost
its bright silver hue, and to be, as it were, smeared ov^r with a
kind of mucus, or with matter, but not with blood. Every hour
after this period, all the symptoms are exasperated, and advance
with hasty strides: the head-ach and thirst become more intense,
the strength decreases, the rigors are more frequent, and at last
convulsive motions, attended in some with delirium, in others with
paralysis, or comatose stupidity, finish the tragedy.'
'The whole process of this very terrible disease is very accurately related
and very justly accounted for, by Theodoric. " Si vero ob ictus veiiementiam,
" dura nialer ah esse fuerit separwla : vel aliqiio modo Isesa (sano &, ill8eso
" existente cranio) sic cognosces : cum dolor capitis, li. lenta febris, singulis
" diebus augmentantur, oculorum anguli, ac si spasmari vellent, distorquen-
" tur ; gense rubent ; (quod signum pravum est in qualibet capitis Ijesione;)
" pannus balneatus superpositus, citius desiccatur ; cutis etiam arida et sicca ;
" et si vulnus fuerit, et, os disco-opertum, color ossis velocius alteratur; et
" propter negligentiam curse, Kgro superveniuTit dolores, et febres, spasmus,
" syncope, et permistio rationis."
Theohor de viiln. capic.
" Qua vero super cerebri membranam sit, ulraqua ratione difficilis est .-
" ns'.m leesis membi-anis apparet ; ideo enim febris cum horrore accediuit, fli-
" ciei rubor, et calor, longe mnjor qiiam pro febris modo ; somnique tumul-
" tuosi ; oculi subf^ngues, et giainiosi et rubentes."
Archigesks fie sangvine svbtercurrente.
Petrus e Largelata, having very accurately related the s) mptoms attending
the formation of matter under the ci-aiiium when fiacturcd, says: " Si autem
FROM EXTERNAL VJOLENOE. 51
If the scalp has not been divided or removed till this point of
time, and it be done now, a very offensive discoloured kind of
fluid will be found lying on the bare cranium, whose appearance
will be still more unlike to the healthy natural one: if the bone be
now perforated, matter will be found between it and the dura ma-
ter, generally in considerable quantity, but different in different
cases and circumstances. Sometimes it will be in great abun-
dance, and diffused over a very large part of the membrane; and
sometimes the quantity will be less, and consequently the space
which it occupies smaller. Sometimes it lies only on the exte-
rior surface of the dura mater; and sometimes it is between it
and the pia mater, or also even on the surface of the brain, or
within the substance of it.
The primary and original cause of all this, is the stroke upon
the skull: by this the vessels which should carry on the circula-
tion between the scalp, pericranium, scull, and meninges, are in-
jured, and no means being used to prevent the impending mis-
chief, or such as have been made use of proving ineffectual, the
necessary and mutual communication between all these parts
ceases: the pericranium is detached from the scull, by means of a
sanies discharged from the ruptured vessels; the bone being de-
prived of its due nourishment and circulation loses its healthy ap-
pearance; the dura mater (its attaching vessels being destroyed,
or rendered unfit for their office) separates from the inside of the
cranium, inflames, and suppurates.
Whoever will attend to the appearances which the parts con-
cerned make in every stage of the disease, to the nature of the
symptoms, the time of their access, their progress, and most fre-
quent event, will find them all easily and fairly deducible from
the one cause, which has just been assigned, viz. the contusion.
As the inflammation and separation of the dura mater is not an
imimdiate consequence of the violence, so neither are the symp-
toms immediate, seldom until some days have passed; the fever
" fractura sit parva et penetrans, tunc fiiint ilia signa post aliquod tempus;
" eo quod tunc humiditates qtiae sunt sub cranio putrefiunt; et tunc fiunt ilia
" accidentia :" And then very justly adds, " Secundo notes quod omnia ilia
" accidentia possunt advenire ex percussione capitis, cranio non fracto."
Pet. £ Labg£i.ata.
53 INJURIES OF THE HEAD
at first is slight, but increases gradually; as the membrane be-
comes more and more diseased, all the febrile symptoms are
heightened; the formation of matter occasions rigors, frequent
and irregular, until such a quantity is collected, as brings on de-
lirium, spasm, and death.
Hitherto I have considered this disease, as unaccompanied by
any other, not even by any external mark of injury, except per-
haps a trifling bruise of the scalp; let us now suppose the scalp
to be wounded at the time of the accident, by whatever gave the
contusion; or let us suppose, that the immediate symptoms having
been alarming, a part of the scalp had been removed in order to
examine the scull; in short, let the injury be considered as joined
with a wounded scalp.
In this case, the wound will for some little time have the same
appearance as a mere simple wound of this part, unattended with
other mischief, would have; it will, like that, at first discharge a thin
sanies, or gleet, and then begin to suppurate; it will digest, begin
to incarn, and look perfectly well; but, after a few days, all these
favourable appearances will vanish; the sore will lose its florid
complexion and granulated surface; will become pale, glassy, and
flabby; instead of good matter, it will discharge only a thin dis-
coloured sanies; the lint with which it is dressed, instead of com-
ing off easily, (as in a kindly suppurating sore,) will stick to all
parts of it; and the pericranium, instead of adhering firmly to the
bone, will separate from it, all round, to some distance from the
edges.''
This alteration in the face and circumstances of the sore is
produced merely by the diseased state of the parts underneath
•« " Ubicunque autem ex vulnere intereundum sit, neque possit homo
" sanitatem recipere, neque servavi, ex his intelligere convenit moriturum ;
" et quod futurum est prognosticare. Hyeme plerumque, ante diem quar-
*' tum, sestate post septimum, accedit febris ; quae quum supervenit, vuhius
"redditnon sui coloris, etsaniem modicam effundit, quodque ex ipso inflam-
" matum est emoritur, glutinosum efRcitur, et camera sale conditam reprse-
"sentat."
HippocHATES de vuln. capit.
" Ulcus neque alitur neque pus maturat, et sordidum sit."
AnCHIGESES.
FROM EXTERNAL VIOLENCE. 53
the scull; which is a circumstance of great importance, in
support of the doctrine advanced; and is demonstrably proved,
by observing that this diseased aspect of the sore, and this
spontaneous separation of the pericranium, are always con-
fined to that part which covers the altered or injured portion
of the dura mater, and do not at all affect the rest of the scalp;
nay, if it has by accident been wounded in any other part,
or a portion has been removed from any part where no injury has
been done to the dura mater, no such separation will happen; the
detachment above will always correspond to that below, and be
found no where else.
The first appearance of alteration in the wound immediately
succeeds the febrile attack; and as the febrile symptoms increase,
the sore becomes worse and worse, that is, degenerates more and
more from a healthy, kindly aspect.
Through the whole time, from the first attack of the fever, to
the last and fatal period, an attentive observer will remark the
gradual alteration of the colour of the bone, if it be bare. At first
it will be found to be whiter, and more dry, than the natural one;
and as the symptoms increase,^ and either matter is collected, or
the dura mater becomes sloughy, the bone inclines more and more
to a kind of purulent hue, or whitish yellow; and it may also be
worth while in this place to remark, that if the blow was on or
very near to a suture, and the subject young, the said suture will
often separate in such manner as to let through it a loose, painful
1 "Tandem subpalHdum vel album se ostendit; ubi autem jam purulen-
" turn est, aut.pustulcc in lingua nascuntur, laborans mente non constante con-
" sumitur."
Hippocrates de indn. capitis.
" Quando sanies est infra cranium, ipso non fracto, cranium est male colo-
"ratum: aeger sentit gravidinem in ea parte qua est sanies. — Est os sanum,
" id est illud cui adhseret dura mater coloris albi, misti rubedine. — Et quo
<*separatio est major, eo major ossisquantitas est mutata in colore. — Ultra
" yero colorem, cognoscitur etiam eo quod siccius sit sano. — Et ultra colorem
" et siccitatem, quando incipit ista separatio, incipiunt aliqua sseva acci-
" dentia ; et febris, mentis alienatio, stupor, vigilae, &c. Quia incipit supra
"■ pamuculum aggregari materia, qux incipit corrumpi."
Jacobus Berksgarius Cabfeksis.
54 INJURIES OF THE HEAD
ill-natured fungus; at which time also it is no uncommon thing for
the patient's head and face to be attacked with an erysipelas.™
I have saidj that in those cases in which the scalp is very little
injured by the bruise, and in which there is no wound, nor any
immediately alarming symptoms or appearances, that the patient
feels little or no inconvenience, and seldom makes any complaint,
until some (ew days are past. That at the end of this uncertain
time, he is generally attacked by the symptoms already recited;
that these are not pressing at first, but that they soon increase to
such a degree, as to baffle all our art: from whence it will appear,
that when this is the case, the patient frequently suffers from what
seems at first to indicate his safety, and prevents such attempts
being made, and such care from being taken, as might prove pre-
ventative of mischief.
But if the integuments are so injured as to excite or claim our
early regard, very useful information may from thence be collect-
ed; for whether the scalp be considerably bruised, or whether it
be found necessary to divide it for the discharge of extravasated
blood, or on account of worse appearances, or more urgent symp-
toms, the state of the pericranium may be thereby sooner and more
certainly known: if in the place of such bruise, the pericranium
be found spontaneously detached from the scull, having a quantity
of discoloured sanies between them under the tumid part, in the
manner I have already mentioned, it may be regarded as a pretty
certain indication, either that the dura mater is beginning to sepa-
rate in the same manner, or that if some preventative means be
not immediately used, it will soon suffer; that is, it will inflame,
separate from the scull, and give room for a collection of matter
between them. And with regard to the wound itself, whether it
was made at the time of the accident, or afterward artificially, it
is the same thing; if the alteration of its appearance be as I have
related, if the edges of it spontaneously quit their adhesion to the
bone, and the febrile symptoms are at the same time making their
attack, these circumstances will serve to convey the same informa-
tion, and to prove the same thing."*
"* " Suturas tempore curationis disjungi grave est."
Archigises de SiGirrs.
" Si dans ane playe contuse, otj le crane est decouvert, on trouve a la cir-
FROM EXTERNAL VIOLENCE. 55
This particular effect of contusion is frequently found to attend
«n fissures and undepressed fractures of tiie cranium, as well as
on extravasations of fluid, in cases where the bone is entire; and,
on the other hand, all these do often happen without the concur-
rence of this individual mischief. All this is matter of accident;
but let the other circumstances be what they may, the spontaneous
separation of Ihe altered pericranium, in consequence of a severe
blow, is almost always followed by a suppuration between the
cranium and dura mater; a circumstance extremely well worth
attending 'to in fissures and undepressed fractures of the scull, be-
cause, it is from this circumstance principally that the bad symp-
toms and the hazard in such cases arise.
It is no very uncommon thing for a smart blow on the head to
produce some immediate bad symptoms, which after a short space
of time diappear, and leave the patient perfectly well. A slight
pain in the head, a little acceleration of pulse, a vertigo and sick-^
ness, sometimes immedicitely follow such accident, but do not con-
tinue many hours, especially if any evacuation has been used.
These are not improbably owing to a slight commotion of the
brain, which, having suffered no material injury thereby, soon
cease. But if, after an interval of some time, the same symptoms
are renewed; if the patient, having been well, becomes again
feverish and restless, and that without any new cause; if he com-
plains being languid and uneasy, sleeps disturbedly, loses his ap-
petite, has a hot skin, a hard quick pulse, and a flushed, heated
countenance; and neither irregularity of diet, nor accidental cold,
has been productive of these; mischief is most certainly impend-
ing, and that most probably under the scull.
If the symptoms of pressure, such as stupidity, loss of sense,
voluntary moiion, &c. appear some few days after the head has
suffered injury from external mischief, they do most probably imply
aneffusionof a fluid somewhere: this effusion may be in the sub-
stance of the brain, in its ventricles, between its membranes, or on
conference de la playe, que le pericrane tienne pen a crane, ou en soit de-
tache, c'est une preuye certaine que le crane a soiifFert, quoiqu'il ne soit
fracture ; et s'il a soufFert, on peut etre assure que la dure mere a souffert
aussi.
Le Drak.
S6 INJURIES OF THE HKAD
the surface of the dura mater; and which of these is the real
situation of such extravasation, is a matter of great uncertainty,
none of them being attended with any peculiar mark or sign that
can be depended upon as pointing it out precisely; but the inflam-
mation of the dura mater, and the formation of matter between it
and the scull, in consequence of contusion, is generally indicated
and preceded by one which I have hardly ever known to fail, I
mean a puffy, circumscribed, indolent tumor of the scalp, and a
spontaneous separation of the pericranium from the scull under
such tumor."
These appearances, therefore, following a smart blow on the
head, and attended with languor, pain, restlessness, watching,
quick pulse, head-ach, and slight irregular shiverings, do almost
infallibly indicate an inflamed dura mater, and pus either forming
or formed between it and the cranium. p
By detachment of the pericranium, I do not mean every sepa-
ration of it from the bone which it should cover. It may be, and
often is cut, torn, or scraped off, without any such consequence;
but these separations are violent, whereas that which I mean is
spontaneous, and is produced by the destruction of those vessels by
which it was connected with the scull, and by which the commu-
nication between it and the internal parts was carried on; and
° Lorsqu'on trouve le perlcrane detaclie, il n'y a point a hesiter a. faire le
tvepan. Je S9ais que dans ua cas pareii on n'auroit rien trouve d'epanchd
sous le crane, mais cependant I'operation faite de bonne heure auroit et^
I'unique mo} en de sauver le malade s'il etoit possible, &c.
Si done plusieurs experiences nous apprennent que la dure mere devient
malade en consequeiice de la contusion de I'os, et que sa maladie degenere
en pournturCjCe qui a jusqii'icl empore plusieurs malades malgre de recours
usites, il faut absolument trepanner de bonne heure.
Le Dkak.
P Si statira ab initio febris primo aut secundo appareat die, ilia procul dubio
causam agnoscat perturbalionem humorum, ac animi, quum vulnus incute-
retur ; cessante causa procatarctica ; ac ubi se collegerit seger, desinat ilia
febricula. Si vero primis diebus, nihil febrile, nee ullum symptoma sentiat
jeger, seque in nuUo discrimine existimat, hunc si subito, die scilicet septimo,
vel quarto decimo (nihil licet in victu, rebusve externis peccaverit seger) ac
prster expectationem febris invadat, significat latens aliquod, in cranio^ ce-
rebro, aut corpore vulnerati.
Pet. Paaw. in Hippoubat.
FROM EXTERNAL VIOLENCE. 6t
therefore it is to be observed, that it is not the mere removal of
that membrane which causes the bad symptoms, but it is the in-
flammation of the dura mater, of which inflammation this sponta-
neous secession of the pericranium is an almost certain indica-
tion.
A false notion prevailed for many years, that the dura mater was
not in general connected with the internal surface of the scull, ex-
cept at the sutures; and that in all other parts of it, such a vacancy
was left as gave free room for what they called its pulsatory mo-
tion.i This opinion, which was embraced by many, even of the
9 If we consider how clearly and plainly many of the best ancient writers
describe the intimate connexion between the scull and dura mater, and how
perfectly well acquainted many of them were with its morbid separation, we
shall wonder how it came to be again foi'got ; but that it was, is most certain.
In Hippocrates, Paulus JEgineta, Rhazes, and others, are many passages
which prove their knowledge of the natural structure and adhesion of this
membrane ; and that some of the most eminent writei's and practitioners had
forgot, or did not attend to it, the following quotations, selected from many
more, may evince.
" Dura mater calvariae connectitur futurarum ope ut pensile et erectum
"teneat cerebrum; turn etiam ut per suturas egressa pericranium procreat:
" spatium vero inter suturas recte natura liberum reliquit ut vacuum quod-
" dam esset inter duram matrem et calvariam ; has nimirum ob causas ; prime
" ne quicquam cerebri systolse et diastolje obstaret ; secundo ne venae, et ar-
"teriae per externam duras matris partem sparsae levi ahquo ictu in cranio
"facto rumperentur; postremo ut ruptis in dura matre venis, sanguis non
" inter duram et piam matrem, sed inter duram et cranium effunderetur, et
" cranio perforato facilius extraheretur. Et hie est ordinarius naturae ordo."
Gui, Fab. Hild.
Felix Wirtz says, that the elevation of the cranium in shght impressions is
needless. " Id enim motum cerebri, propter vacuum et distantiam quae est
" inter meningem et cranium, minime impedire." And Hildanus, by way of
reproof to what Felix Wirtz says : " Aliquando duram matrem cranio undique
" adliaerere vidimus."
Fallopius, speaking of the dura mater, says : " Continue pulsat, quare non
" facile sanatur."
Petruse Marchetti supposed the dura mater always to be at a distance from
tlie scull in those who were bald. Speaking of the treatment of a particular
case, he says : " Post septimam nempe oleum hyperici, quia calvus erat pa-
" tiens atque membrana a calvaria distabat; quod in calvis semper observavi."
Pet. e Marchetti Obs. Chir.
" Aliquando contingit ut dura mater cranio satis firmiter adbaereat, sed haec
" admodum raro evenire solety atque prxter nature consuetudinem est."
Mttxs Pmx. Rat. Chinirg.
VOL. I. H
58 INJURIES OF THE HEAD
most eminent practitioners, was the principal reason why the bad
effects of contusions of the head were so little understood, and so
grossly mistreated by them. They supposed that the vacuity be-
tween the dura mater and cranium was sufficient, in general,
to defend the former from all external violence; and the blood and
matter so often found between them were thought to be deposited
in a space naturally vacant. Upon this principle stood both their
opinion and practice; and therefore it is not to be wondered at,
that their accounts, in general, are so perplexed, and so seldom
verified by the examination of dead subjects.
It sometimes happens, that the scalp is so wounded at the time
of the accident, or so torn away, as to leave the bone perfectly
bare; and yet the violence has not been such as to produce the evil
I am now speaking of. In this case, if the pericranium be only
turned back, along with the detached portion of scalp, there may
be probability of its reunion, and it should therefore be imme-
diately made clean and replaced for the purpose of such experi-
ment, which, if it succeed, will save much time, and prevent con-
siderable deformity. If this attempt do not succeed, the detached
piece may be removed, and the case then becomes as if the scalp
and the pericranium had been forced away at the time that the
wound was first inflicted; and the worst that can happen, will be
an exfoliation from the bare scull."^
This was also the opinion of Sylvius, Pacchioni, Ambrose Pave, Serjeaiit
Wiseman, Baglivi, Barbette, and of all tliose who maintained the doctrine of
the oscillation of the dura mater, and who believed that that membrane was
found sometimes liig-her, sometimes lower, that is, sometimes nearer to,
sometimes farther from the sculi, at one age, and at one time of the moon,
than another.
' Not that exfoliation is the necessary consequence of the scull being laid
bare : this depends upon other circumstances, besides the mere removal of
the scalp and pericranium. Tlie solidity of the surface of the bones, the size
of the vessels, and the impulse of the blood through them, are what princi-
pally determine that. If the cortex of the bone be not very hard, and the
impulse of the blood be capable of counterbalancing the effects of the exter-
nal air, a granulation of flesh will be generated on the surface of the bone,
which will cover and firmly adhere to it, without throwing off the smallest
exfoliation, especially in young subjects. On the contrary, if the bone be
much hardened, and the vessels thereby constringed ; or if such apjilications
be made use of, as will produce an artificial constriction of them, the surface
PROM EXTERNAL VIOLENCE. 59
It does also sometimes happen, that the force which detaches or
removes the scalp, does also occasion the mischief in question; but
(he integument being wounded, or removed, we cannot have the
crilerion of the tumour of the scalp, for the direction of our Jjudg-
ment. In these circumstances, our whole attention must (as I
have already said) be directed to the wound and general symp-
toms: the edges of the former will (as I have already observed)
digest as well, and look as kindly, for a few days, as if no mis-
chief was done underneath; but, after some little space of time,
when the patient begins to be restless, and hot, and to complain
of pain in the head, these edges will lose their vermilion hue, and
become pale and flabby; instead of matter they will discharge a
thin gleet, and the pericranium will loosen from the scull to some
distance from the said edges: immediately after this, all the gene-
ral symptoms are increased and exasperated; and, as the inflam-
mation of the membrane is heightened, or extended, they become
daily worse and worse, until a quantity of matter is formed, and
collected, and brings on that fatal period, which, though uncertain
as to date, very seldom fails to arrive.
The method of attempting the relief of this kind of injury con-
sists in two points, viz. to end'eavour to prevent the inflammation
of the dura mater; or, that being neglected, or found impracticable,
to give discharge to the fluid collected within the cranium, in con-
sequence of such inflammation.
Of all the remedies in the power of art, for inflammations of
membranous parts, there is none equal to phlebotomy. To this
truth many diseases bear testimony; pleurisies, ophthalmies, stran-
gulated hernias, &c.: and if any thing can particularly contribute
to the prevention of the ills likely to follow severe contusions of
the head, it is this kind of evacuation; but then it must be made-
use of in such a manner as to become truly a preventative, that is,
it must be made use of immediately, and freely.
I am very sensible, that it will in general be found very diffi-
cult to persuade a person, who has had what may be called only a
will necessarily become dry, and tlie juices ceasing to circulate through it, it
must part w'lih a scale to a certain deptli ; that is, that part of the surface
through which the circulation ceases to be carried on will be separated frorBj
and cast off bv the vessels \\ hich nourish the rest of liie bone.
^'''
60 INJURIES OF THE HEAD
knock on the pate, to submit to such discipline, especially if he lind
himself tolerably well. He will be inclined to think, that the sur-
geon is either unnecessarily apprehensive, or guilty of a much
worse fault; and yet, in many instances, the timely use or the ne-
glect of this single remedy, makes all the difference between safety
and fatality.
It may be said, that as the force of the blow, the height of the
fall, the weight of the instrument, &c., can never precisely or cer-
tainly determine the effect, nor inform us whether mischief be
done under the bone or not, a large quantity of blood may be
drawn off unnecessarily, in order to prevent an imaginary evil.
This is in some degree true; and if the advice which I have just
given were universally followed, many people would be largely bled
without necessity; but then, on the other hand, many a very valu-
able life would be preserved, which, for Want of this kind of as-
sistance, is lost. " Nihil interest, praesidium an satis tutum sit,
" quod unicum est," is an incontested maxim in medicine; and if
it be allowed to use such means as may be in themselves hazard-
ous, surely it cannot be wrong to employ one which is not so; at
least, if it be considered in a general sense, whatever it may acci-
dentally prove to some few particular individuals.
Acceleration, or hardness of pulse, restlessness, anxiety, and
any degree of fever, after a smart blow on the head, are always to
be suspected and attended to. Immediate, plentiful, and repeated
evacuation by bleeding, have, in many instances, removed these,
in persons to whom, I do verily believe, very terrible mischief
would have happened, had not such precaution been used. In
this, as well as some other parts of practice, we neither have, nor
can have any other method of judging, than by comparing together
cases apparently similar. I have more than once or twice seen
that increased velocity and hardness of pulse, and that oppressive
languor, which most frequently precede mischief under the bone,
removed by free and repeated blood-letting; and have often, much
too often, seen cases end fatally, whose beginnings were full as
plight, but in which such evacuation had been either neglected or
not complied with.
I would by no means be thought to infer from hence, that early
bleeding will always prove a certain preservative, and that they
FROM EXTERNAL VIOLENCE. 61
only die to whom it has not been applied: this, like all other hu-
man means, is fallible; and perhaps there are more cases out of
its reach, than within it; but, where preventative means can talcQ
place, this is certainly the best, and the most frequently success-
ful.
The second intention, viz. for procuring the discharge of matter
collected under the cranium, can be answered only by the perfo-
ration of it.
When, fiom the symptoms and appearances already described,
there is just reason for supposing matter to be formed under the
scull, the operation of perforation cannot be performed too soon;
it seldom happens that it is done soon enough.*
The propriety or impropriety of applying the trephine, in cases
where there is neither fissure, fracture, nor symptom of extrava-
sation, is a point which has been much litigated, and remains still
unsettled either by writers or practitioners.
When there is no reason for suspecting any of those injuries,
either from the symptoms, or from the appearances; and the peri-
cranium, whether the scalp be wounded or not, remains firmly at-
tached in all parts to the scull; there certainly is not (let the
general symptoms be what they may) any indication where to
apply the instrument, and consequently no sufficient authority for
using it at all: but whenever that membrane, after the head has
received an external violence, separates, or is detached spontane-
ously from the bone underneath it, and such separation is attended
with the collection of a small quantity of thin, brown ichor, an
alteration of colour in the separated pericranium, and an unna-
tural dryness of the bone, I cannot help thinking, that there is as
good reason for trepanning, as in the case of fracture; I believe
experience would vindicate me, if I said, better reason; since it
is by no means infrequent for the former kind of case to do well
without such operation, whereas the latter (I mean suppuration
under the scull) never can.*
s " His, ubi cito manus admoveatur, salutis aliqua spes subest ; ubi serius,
" plerique otnnes moriuntur."
Ahchigewes.
t Les auteurs jusqii'ici ne nous ont parle du trepan qa'autant qu'il pouvoit
servir a relever des pieces du crane enfoncees par un coup violent, ou »
62 INJURlliS OF THE HEAD
All the best practitioners have always agreed in acknowledging
the necessity of perforating the scull in case of a severe stroke
piade on it by gun-shot, upon the appearance of any threatening
symptoms, even though the bone should not be broken; and very
good practice it is. A wound by gun-shot (as far as it relates to
the scull) is to be regarded only as one attended with a very high
degree of contusion, and therefore most likely to produce symp-
toms accordingly; among which, inflammation of tiie dura mater
stands principal. Experience confirms both; most of the symp-
toms attending wounds of the head, made by gun-shot, are symp-
toms of contusion; and the formation of matter between the
cranium and dura mater is a very frequent and a very fatal con-
sequence of such contusion.
In short, the spontaneous separation of the pericranium, if at-
tended with general disorder of the patient, with chilness, horri-
pilatio, languor, and some degree of fever, appears to me, from
all the observation I have been capable of making, to be so sure
and certain an indication of mischief underneath, either in pre-
sent, or impending, that I should never hesitate about perforating
the bone in such circumstances.
When the scull has been once perforated, and the dura mater
thereby laid bare, the state of the latter must principally deter-
mine the surgeon's future conduct. In some cases, one opening
will prove sufficient for all necessary purposes, in others several
may be necessary. This variation will depend on the space of
detached dura mater, and the quantity of collected matter. The
repetition of the operation is warranted, both by the nature of the
case, and by the best authorities; there being no comparison to be
made between the possible inconvenience arising from largely de-
nuding the dura mater, and the certain as well as terrible evils
which must follow the formation and confinement of matter be-
tween it and the scull.
donii6 issue a quelque liqueui", comme seroit du sang, ou du pus, epanclie,
sous le crane.
La contusion de I'os est un cas, oii le trepan n'est pas moins necessaire ;
lion a cause que I'os est contus, mais pour prevenir la maladie de la dure
mire, et de la pie mere; qui en estune suite presque indispensable.
Le Dean,
FROM EXTERNAL VIOLENCE. 63
It can hardly be necessary for me to observe, to whoever re-
flects ever so little on the true nature of these cases, that notwith-
standing the operation of perforation be absolutely and unavoid-
ably necessary, yet the repetition of blood-letting, of cooling laxa-
tive medicines, the use of antiphlogistic remedies, and a most
strict observance of a low diet and regimen, are as indispensably
requisite after such operation as before; the perforation sets the
membrane free from pressure, and gives vent to collected matter,
but nothing more; the inflamed state of the parts under the
scull, and all the necessary consequences of such inflammation,
call for all our attention, full as much afterwards as before; and
although the patient must have perished without the use of the
trephine, yet the merely having used it will not preserve him,
without every other caution and care.
This being all that our art is capable of doing in these melan-
choly cases, I wish I could say, that it was most frequently suc-
cessful. Sometimes it is: the operation, considered abstractedly,
is not in itself hazardous, and is the unicum remediwn for the most
immediately -impending and most threatening mischief: some have
been saved by it, none can escape without it. As there are no
certain indications, no criteria^ whereby we are enabled to judge
whether it will prove successful or not, the event of each indi-
vidual case can alone determine. When that is happy, the means
are very justly commended; but when it is not so, they ought not
therefore to be condemned; since they are built on rational prin-
ciples, and are the only means in human power.
CASE I.
A POOR fellow crossing Tower-hill, got, before he was aware
of it, into a mob, that was endeavouring to rescue a sailor from a
press-gang. The man was knocked down. When the crowd
dispersed, he was found senseless, and in that state was brought
to St. Barthoiomew's hospital, where he was immediately let
blood, and put to bed. In an hour or two, he was so recovered, as
to be able to give the preceding account.
When Mr. Nourse (whose week it was for accidents) saw him
64 INJURIES OF THE HEAD
the next day, the man appeared to be perfectly well, nor did any
mark of violence appear on his head, except one small bruise, and
that so slight, that it might, with more probability, be attributed
to the fall than the blow. However, as he was positive that he
had been knocked down, by a very smart blow, from a heavy
weapon; and as he certainly had been deprived of sense a con-
siderable time thereby; Mr. Nourse bled him again, and ordered
him to be kept in bed, and to a very low diet. At the end of
three, days the man found himself so well, as to leave the hospital,
and go to work. On the twelfth day from that of the accident,
he came to my surgery, and complained of being much out of
order; said that his head was very uneasy; that he was hot, thirsty,
got little or no sleep, and was at times so faint that he could not
pursue his labour. He looked ill, assured me he had lived very
soberly from the time of his leaving the hospital, and that he had
been in his present state for three days past. I took him into the
house again, bled him, ordered him a clyster immediately, and that
he should be kept in bed.
Next day (13th) he was in much the same state a& the preced-
ing; he had passed a restless night, had dosed now and then, but
awoke with much disturbance. He had a hot skin, and a flushed
countenance, mixed with a light yellow tint; he complained of
general pain and tightness all over his head, but neither to the
sight nor to the touch was there any appearance, or sensation,
whereon to build a probable supposition of particular mischief.
He was again, by the physician's order, let blood, and directed to
take the sal absinthii mixture, with a few grains of rhubarb in it,
every six hours. He passed the ensuing night in a disturbed
manner, and the next day (the 14th) was apparently worse; his
skin was hotter, his pulse quicker, and his pain more acute; he
also now thought, that one part of his head was tender to the
touch, and said, he was sure that was the part that received the
blow. This place I examined. The scalp did seem to be rather
fuller than natural, but by no means sufficiently so to enable me to
form any judgment by. Toward the close of this day he had a
slight shivering, was sick, and vomited, and passed the following
night without any sleep at all; talking sometimes incoherently,
but still capable of giving a rational answer to any question which
FROM EXTERNAL VIOLENCE. UO
engaged his attention. On the 15th day, the tumor of the scalp
was more apparent, but yet seemed to contain little or no fluid, and
was about the breadth of a crown piece. I would have removed
that portion of scalp; but while I was intending it, the poor man
bad a very severe rigor, which disordered him so much, that he
begged to be let alone for the present. That afternoon he had
two more shiverings, passed very ill the following night, and next
morning was delirious. The tumor now was more risen, con-
tained palpably a fluid, but was by no means tense; I took away
the whole tumid piece, by a circular incision, gave discharge to a
thin brown sanies, and found the cranium perfectly naked, altered
considerably in colour from that of a healthy natural one, but with-
out fissure, fracture, or other evil. That whole night and next
day he was delirious; his skin burning hot; he had frequent spasms,
which shook his whole frame, and the next night (the 17th) he
died.
The whole scalp, except round the edge of the incision, was in
a natural state; the pericranium in every other part, except the tu-
mid one, adhered to the bone; and neither inflammation, nor tumor
of any kind, all over the rest of the head. Under that part of tli,e
scull from which the pericranium had been detached, and from
which the scalp had been removed, a very considerable collection
of matter was found lying between the dura mater and cranium,
but no appearance of disease any where else.
CASE II.
CONTUSION WITH WOUND.
A YOUNG fellow, playing at quoits, was struck down by the
perpendicular fall of one of them on his head. It made a large
wound, which bled freely, but did not divide the pericranium,
and consequently did not denude the scull. The wound was
brought together by a stitch made by somebody at hand; and the
man, though stunned at first by the blow, having vomited plenti-
fully, was soon well, and the next day went to his work, which
was that of a farrier. The wound was dressed daily with a su-
TOL. I. I
66 INJURIES OF THE HEAD
perficial pledget, by the person who first saw and stitched it; and
it seemed to unite kindly.
On the sixth day from that of the accident, he complained of
being chilly and faint; and when he had done about half a day's
work, found himself unable to bear the heat of the forge, or to
stoop to shoe a horse, on account of pain in his head; he there-
fore left his shop, went home, and sent for the apothecary who
first had dressed him. The wound, not being very carefully exa-
mined, appeared to be healed, and therefore was not regarded as
any cause of the man's present indisposition, who was treated as
having a fever from cold and irregularity: he was let blood, and
took some medicines; but at the end of three days (nine from the
accident) being worse, and incapable of bearing the expense of
remaining at home, he was brought to St. Bartholomew's hospi-
pital. On the tenth day from that on which he was wounded, I
saw him. He had a considerable degree of fever; his pulse was
hard and quick, his skin hot and dry, his face flushed, his eye
languid, and he complained of great pain and tightness all over
his head. The wound was apparently but not really healed; I
could pass a probe underneath, from one end to the other of it;
and I could feel the cranium bare the whole way. I divided its
whole length; found the pericranium sloughy, and detached to a
considerable distance, and the bone much altered in colour; upon
sight of which, I removed the whole separated part, by a large
circular incision.
From the symptoms and appearances I prognosticated no good.
He was again let blood, and had a clyster, and a lenient purge,
which together produced three stools. That night (the 10th) he
had a rigor, after which his pain became more intense, and fever
higher.
The next morning (the 11th) he had another shivering; and
when I saw him about noon, he was very inconsistent. I set on
a trephine close to the sagittal suture on one side; and gave dis-
charge to a small quantity of matter which lay on the surface of
the dura mater; after being lightly dressed, some more blood was
drawn from one of the jugular veins, and he was ordered to take
a draught of the salt of wormwood mixture frequently. The next
day (the 12th) he was worse. I therefore set the trephine on
FROM EXTERNAL VIOLENCE. 67
again, but on the other side of the suture, and by that means let
out a considerable quantity of matter from between the scull and
membrane. Soon after this he became more rational, and seemed
to get a little sleep; but in the evening his pain returned with
great violence, and he had a rigor which held him above an hour..
When I saw him the next day (the 13th) he was senseless, had
a low faltering pulse, and a profuse cold sweat; soon after which
he expired.
Upon removing the upper part of the scull, a large quantity of
matter was found Imder each parietal bone, which had detached
the dura mater from its connexion with the scull for a considera-
ble space, but not at the suture. On the right side a portion of
the dura mater was become sloughy, about the breadth of a shil-
ling; and under this altered part was matter between the two
meninges.
The more firm attachment of the dura mater at the sutures,
renders the separation of it at these places very difficult: which
circumstance, added to the consideration of the situation of the
sagittal suture on the very top of the head, renders the application
of the trephine on each side of it often absolutely necessary. For
if there be good reason to suspect either an extravasation of blood,
or a collection of matter in consequence of a blow received on
this suture, and one side only be perforated, the operation may
happen to be performed on that side where the blood or matter
does not lie, and will therefore be successless; or, on the other
hand, the extravasation or suppuration may be on both sides; and
then the perforation of one only cannot answer the whole pur-
pose, and the patient will as certainly perish as if nothing had
been done at all.
CASE III.
CONTUSION WITHOUT WOUND.
A BOY about nine years old, playing under an empty cart, whose
shafts were supported by a stick, was knocked down by the fall
of one of them upon his head. The child was stunned by the
68 INJURIES OP THE HEAD
blow for a minute or two, but soon became sensible. When he
came home, there being a small swelling where the blow had
been stricken, his mother applied a bit of linen rag, wet with
vinegar; and as he appeared to be perfectly well, in a day or two
he was sent to school.
Five days passed over before he made any complaint: on the
sixth, he said that his head ached; he brought up his breakfast,
and could eat no dinner; but in the evening seemed to be pretty
well again. On the 7th he complained still more of his head,
and said that he was very sick and very cold. He was put to
bed, but got no rest. As he had not had either small-pox or
measles, he was brought home, and treated as if one of these dis-
eases was to follow.
Three days more passed, and no eruption appeared: the fever
continued much the same; he was frequently inclined to vomit;
and what little sleep he got, was extremely disturbed. He was,
by the order of a physician, let blood, had a blister applied to his
back, and took some of the common febrifuge medicines. On
the 12th day from that of the accident, he was seized with a
shivering, which held him more than a quarter of an hour; after
which his pain became more acute and his fever higher. Some
blood was drawn from his temples by leeches, and he was order-
ed some other medicines. On the 13th at noon, he had another
rigor, still more severe than the former, and of longer duration;
and that evening he became light-headed. By some means or
other, the accident of the blow was now mentioned to the person
who attended him, and who desired that a surgeon might look at
his head. I found about a third part of the left parietal bone co-
vered by a flattish tumor, containing a fluid.
From the appearance of this swelling, from the date of the ac-
cident, the attack, violence, and duration of the symptoms, I made
no scruple to give my opinion, that the blow had been the sole
cause of all the child's illness; that I suspected the scull under
the tumor to be bare, if not injured; that I did also believe, that
matter was forming, or formed, under the scull; and that if the
last conjecture was true, the only chance the child could have of
preservation, must be from the operation of the trephine.
The scalp was divided, and the scull found as I suspected, that
PROM EXTERNAL VIOLENCE. 69
is, perfectly bare, and altered from a natural colour: I would there-
fore have perforated it immediately; but, as the bone was not
broken, the parents objected to such operation; and the physical
gentleman, who had the care of the boy, not having seen much
business of this kind, and not rightly comprehending the true na-
ture of the case, joined in opinion with the parents, that such ope-
ration was not necessary. It was therefore not performed, and
the whole was committed to internal remedies.
The fever increased, and the child's strength decreased in pro-
portion: he continued delirious for three days more, then sank into
a state of insensibility, and died.
Having been contradicted, and (as I thought) somewhat im-
properly over-ruled in the management of the patient while alive,
I was the more importunate to get leave to examine him when
dead.
All that part of the dura mater which bad been covered by the
left parietal, and part of the temporal bone, was detached from the
said bones, and covfered with a considerable quantity of matter.
Under the middle part of the former bone the dura mater was
discoloured and sloughy; this discoloured part I opened with a
lancet, and let out near a spoonful of matter, which matter lay
between the meninges. All the rest of the contents of the head
were unaffected.
When first I saw this child, all chance of relief from evacuation
was over, and his symptoms plainly indicated mischief under the
scull. Nothing, therefore, but perforation could give him any kind
of chance.
I do not say that this operation would have saved him; I am
much inclined to believe that it would not; but still it was the only
thing that could with propriety have been done for him; and tliere-
fore it ought to have been done, instead of wasting time with the
use of internal remedies, from which no possible good could be
expected or derived.
TO INJURIES OF THE HEAD
CASE IV.
CONTUSION WITHOUT WOUND.
A LABOURING man fell from a scaffold, two stories high, by
which he was for a few minutes stunned and insensible, but soon
recovered. He was let blood; and, having bruised his right arm,
and the same side of his forehead, he was properly dressed by
somebody in the neighbourhood.
Next day, being very well, he returned to his labour, and fol-
lowed it daily for five more. On the sixth, finding himself a good
deal out of order, "he came to the hospital for advice. He com-
plained of shooting and frequent pain in his head; of giddiness,
and inclination to vomit; and said, that he felt as if a cord was
drawn tight round his brain. On the right side of his forehead
was a small tumor, neither tense nor painful, but palpably con-
taining a fluid. I persuaded the man to let me open it. I found
a small quantity of a brown fluid, covering the bone, perfectly de-
nuded of its periosteum; upon which discovery, I removed the
whole piece by a circular incision: fourteen ounces of blood were
drawn from his arm; a clyster was thrown up, and he was con-
fined to his bed, and barley-water.
Next morning (the seventh) his pulse was full, hard, and fre-
quent; he had slept very little, and that in a very disturbed manner.
He was, by the physician's order, let blood again, and directed to
take the sal absinthii mixture, with rhubarb sextis horis. On the
eighth day, he was let blood again from one of the jugulars, and
being rather still costive, took a gentle purge. On the ninth, his
pulse was still higher and harder, and his skin more hot and dry;
twelve ounces more of blood were drawn off from one of the tem-
poral arteries. That evening he had a shivering, after which he
complained that his pains were much increased. Next morning
(the tenth) his sore looked very ill: was pale, spongy, and glassy,
and the scalp separated from the scull to some distance beyond
the edges of the wound. 1 set on a trephine, and removed a piece
of the cranium, under which the dura mater was smeared over
FROM EXTERNAL VIOLENCE. *i I
with matter, and had lost its bright colour. That night he got no
sleep, and toward morning had another rigor.
The eleventh, at noon, he was manifestly worse in every re-
spect; his pain was intense, his fever high, and his sore as ill-
conditioned as possible. With the largest trephine I had, I took
away another piece of the cranium, nearer to the temporal bone,
and, by means of this opening, procured the discharge of a consi-
derable quantify of matter. This done, finding his pulse still high
and full, I drew off ten ounces more of blood, and ordered him a
clyster. The loss of blood produced a swooning, which lasted some
minutes, after which, he said that he thought his head was rather
easier. As the evening approached, his pain returned, wherefore
some leeches were applied to his temples. That night he got a
little quiet sleep, and in the morning of the twelfth day said that
his head was perfectly easy: a very large discharge of matter had
been made through the perforation in the cranium, and I thought
that the wound of the scalp wore rather a better aspect. He was
kept strictly to a proper low regimen; took at first the sal absinthii
mixture freely; when his pain had left him, the physician ordered
him the bark; and, in a very kw days, every bad symptom and ap-
pearance left him.
Would not this case, which ended so happily, have been at-
tended withjhe most fatal consequences, if the free perforation
of the scull had been omilted, or if less blood had been drawn
off?
CASE V.
eONTUSION WITH WOUND.
A YOUNG fellow of about twenty years was thrown from an un-
ruly horse against one of the rails in Smithfield. The blow was
great; he lay senseless for above an hour, and in that state was
brought into St. Bartholomew's hospital.
He had a large wound on one side of his forehead, the skin of
which which was partly torn guite off, and partly turned down
73 INJURIES OF THE HEAD
over his eye. The lips of the wound were, by ijie person who
saw him first, brought as near together as they would admit, but
such a portion was lost, as necessarily left the bone bare about
the breadth of a shilling. As soon as his wound had been ex-
amined, he was let blood and put to bed. The next day, his pulse
being hard and full, he was again let blood, and was ordered to
have a clyster, a lenient purge, and some febrifuge medicines.
On the third, the wounded scalp, and that side of the face being
much swollen, a warm cataplasm was applied over the dressings,
and the part was well fomented; and, in about five days more,
every thing wore so good an aspect, that the man seemed to be
getting well apace. On the ninth, he complained of being out of
order, said his head ached, and that he had not slept the preceding
night. He was hot and feverish, and his pulse hard and full. He
was therefore let blood again, and ordered to have a clyster, and to
be kept very low. On the tenth, in the night, he had (as he called
it) a chilliness which came all over him; after which his pain was
considerably increased. On the eleventh, his sore seemed to spread,
discharged a thin gleet instead of matter, the lint with which it
was dressed stuck fast to all parts of it; and its surface, from hav-
ing been florid and granulated, became tawny and spongy. That
day he had another shivering; and, on the next, being the twelfth,
a consultation was held on him. He was now very hot and fe-
verish; his face much flushed, an erysipelas beginning to appear
on his eye-lids, his sore very ill-conditioned, and the bare bone so
much changed from its natural colour, that it looked as if matter
might have been seen through it. Consideratis considerandis, it
was agreed that he had no chance for his life but by perforation of
the bare cranium. The operation was immediately performed,
and a quantity of matter found on the dura mater. For several
days the discharge was great, and the man continued very ill; but
about the eighteenth day the fever left him, he became easy, the
discharge lessened, his sore put on a good face, and he got a na-
tural sleep. From this time nothing sinister happened, and the
man got soon well.
FROM EXTERNAL VIOLENCE- 73
CASE VI.
CONTUSION WITHOUT WOUND.
A LAD about twelve years old, standing by a man who was play-
ing at cricket, received a blow from the bat on his forehead. The
boy became senseless, and as he was not known to any body pre-
sent, he was brought to the hospital. He recovered his senses be-
fore he got thither; but the part which received the stroke being
much swollen, he was dressed, let blood, and ordered to keep in
bed. When I saw him next morning, he had no complaint but
the soreness of his forehead, under the skin of which there seemed
to be a good deal of extravasated, coagulated blood. His pulse
was full and strong; he was therefore again let blood; and as he
had not had a stool for two days, a clyster was thrown up, and a
lenient purge given. A discutient cerate was kept upon his fore-
head; and, being of a costive habit, he was purged once in two or
three days; and, on the ninth from that of the accident, was dis-
charged from the house. On the fourteenth, he returned to it
again, complained of lassitude, giddiness, and head-ach. He was
put under the care of the physician, was let blood, vomited, purged,
and took proper medicines, but remained much the same for three
or four days; that is, he was feverish, with a skin toohot, a pulse
too quick, and what little sleep he got was unquiet and short. On
the seventeenth day he had a slight rigor, during and after which
his pain in the head was much more intense; and the following
day all his febrile symptoms were much exasperated. On the
nineteenth, he complained of tenderness to the touch on his fore-
iiead, and great general pain in his head. He was again let blood,
and was more sunk by the discharge than I could have supposed,
but no remission of his symptoms followed. His sleep that night
was very little, and very unquiet; toward morning he had two
distinct shiverings; and when I saw him at noon, oil the twentieth,
his forehead appeared somewhat tumid and pufiR'. From the con-
tinuance and exasperation of his symptoms, and from the new ap-
pearance on his forehead, I was almost certain there was mischief
VOL, I. K ■
74 INJURIES OF THE HEAO
on or under the scull; I therefore divided the scalp, to examine the
bone, and found, between it and the pericranium, which had quit-
ted its adhesion for more than the breadth of a crown piece, a
small quantity of a thin, discoloured fluid.
This (as it appeared to me) put the nature of the case out of
doubt, and left the boy no chance, but from perforation. I there-
fore applied the trephine immediately, and gave discharge to mat-
ter formed between the dura mater and bone. For a week after
the operation, the discharge was large, and the boy in much
hazard; but, at the end of that time, the suppuration lessened, the
dura mater incarned kindly, and by proper care, and taking freely
of the decoct, cortic. Peruv. he got well.
CASE VII.
CONTUSION WITHOUT WOUND.
A MAN in the neighbourhood of St. Giles's had a quarrel with
his wife; in which he struck her over the head with a mop-stick.
The blow was a smart one, but as it neither fetched blood, nor
brought her to the ground, it only finished the dispute, and no
farther notice was taken of it. The woman followed her busi-
ness, which was that of crying greens about the streets, and lived
(to use her own words) sometimes drunk, sometimes sober, for a
week. On the eighth day from that of the blow, she found her-
self so ill, that she applied to the hospital for admission; and was
taken in as a physician's patient for a fever. The doctor wrote
for her; and the day after this (the tenth from the accident) the
sister of the ward, in cutting off the patient's hair, which was full
of vermin, discovered a swelling, which she desired me to look
at: it was flattish, about the breadth of the palm of a hand, and
lay immediately across the sagittal suture. The woman had now
a hard full pulse, a hot dry skin, a black tongue, a frequent in-
clination to vomit, great thirst, intense pain in her head, and got
no sleep. From these symptoms and appearances, and from the
account which the woman now first gave of the blow, I made no
hesitation to say, such blow was the cause of all her symptoms.
PROM EXTERNAL VIOLENCE. 75
That night she had a severe rigor, and the next day, the eleventh,
an erysipelas had taken possession of part of her visage. I open-
ed the tumor, and finding the bone bare, cleared away the scalp
largely, and circularly. I then applied a trephine on one side of
the suture and close to it, and found the dura mater altered in hs
natural colour, and, as it were, smeared over with matter. She
passed the succeeding night very ill, was in great pain, got no
sleep, and had two shiverings. When I came to her the next
day, her whole visage was covered with an erysipelas, and so
swollen, that she could not open her eyelids. I applied the tre-
phine on the other side of the suture, and found the same ap-
pearance, viz. matter on the surface of the membrane. She had
within the last two days been let blood three times, and had con-
stantly taken such medicines as the physician had ordered for her,
and which were calculated to abate her fever, and keep her body
open. Her symptoms still continued without abatement, the
wound of the scalp bore as bad an aspect as possible, she talked
very inconsistently, got not a wink of sleep, and called perpetually
for drink. As the quantity of bone made bare by the removal of
the scalp gave room for the farther application of the instrument,
I made a third perforation near to the first, and immediately gave
thereby discharge to so large a quantity of matter, as to satisfy me
tlie event must be fatal.
The next day the right arm and leg became paralytic; and the
day following that, from having been raving, she sunk into a state
of perfect insensibility, had a short, laborious respiration, a small,
interrupted, faltering pulse, and cold extremities, and on the six-
teenth day from that of the accident she died.
Upon opening the head, the dura mater was found covered with
matter, under the whole internal surface of both the parietal
bones; but the firm adhesion of the longitudinal sinus to the sagit-
tal suture had prevented all communication between the two col-
le<;tions of matter.
INJURIES OF THE HEAD,
CASE VIII.
CONTUSION WITH W0UN1>.
A LUNATIC threw himself from a vvindovv, two stories high,
and in his fall struck his head, first against a sign-iron and then
against a slated pent-house.
He was taken up senseless, with three wounds on his head; one
just above the right temple, and two on the top of his head: the
wounds were but small, nor was the pericranium divided in any of
them. He remained stupid above twelve hours; but being in that
space of time let blood freely twice, he recovered his senses, but
shewed no signs of a right understanding. He passed two days
and nights in the utmost disorder and disturbance. He was con-
fined in a strait waistcoat, and kept two people constantly employ-
ed in holding him: at last, by repeated phlebotomy, and taking a
large quantity of opium, he fell asleep, slept near twelve hours, and
then awoke perfectly tranquil, and perfectly rational. By the
sixth day from that of the fall, his wounds were in perfect good
order, and seemed to heal without any trouble; the man was in
very good health and temper, and perfectly rational and intelligent.
He would have been permitted by his friends to have gone out a
little way into the country; but lest there should be any latent
mischief, I advised him to keep quiet a little longer, and to live
with great caution; which advice was followed. On the tenth
day from that of the accident, he lost his appetite, looked dull
and languid, refused food and company, complained that his head
ached, and said that he had not slept. So little time had passed
since he had been disordered in his mind, that from his aspect and
manner I suspected a return of his lunacy. I let him blood again,
directed that he might be kept low, and desired his brother, who
was an apothecary, to give him an opiate at going to bed. The
next day, the eleventh, he said that his head-ach had again pre-
vented him from sleeping all night, and that he felt as if a cord
was bound tight about his brain: his skin was too hot, his pulse
was too hard and too frequent; his urine small in quantity, and
FROM EXTERNAL VJOLENCK. 11
high coloured; and the aspect of the wounds in the scalp by no
means so favourable as they had hitherto been: one of them looked
more spongy and pale than the others. I examined with my probe,
and found the scull bare for some space under it. With his own
and brother's consent, I removed all the scalp covering the bare
cranium, and found it to be considerably altered from a natural
colour. I bled him again, and desired that he might take freely
of the salt of wormwood and lemon-juice until the next day. That
night he had a smart rigor, and the next morning, finding him
worse and more disturbed, I made a perforation of the sCuU. The
.dura mater under this perforation was dull, and had apparently
matter on its surface, though small in quantity. He was dressed
lightly; and, as his pulse would very well bear it, eight ounces
more of blood were drawn off. The following morning, the thir-
teenth, he had a still more severe shivering, his pain in his head
was greater, his fever higher, and the whole sore so crude, that the
lint was with difficulty removed from it. I applied the trephine
again, and found the same appearance, viz. a dull discoloured dura
mater, and a small quantity of matter. That evening he had an-
other rigor, and was the following day manifestly worse. Con-
vinced, from the symptoms, of his hazard, and firmly believing
that matter was collected in such manner as not to be discharged
by the two openings already made, I ventured to make a third,
and that a large one; which produced an immediate and
large discharge of pus. In seven or eight hours I saw him again,
and found him easier and more tranquil. He had slept nearly an
hour, and his pulse did not feel so rapid, nor so hard. That even-
ing he got more sleep, and the following morning answered every
question asked, in such manner as to convince every body that he
was certainly better. To shorten the relation, I shall only add,
that the discharge continued large for several days, and then gra-
dually decreased: all his symptoms by degrees also disappeared,
and hi no great length of time, by proper care, he got very well.
When this patient was attacked with his first symptoms, I did
not suspect the true cause. His want of sleep, his seeming anxie-
ty, his taciturnity, and great unwillingness to answer any ques-
tion, seemed to me to bespeak a return of his maniacal disorder.
Upon this supposition I gave him the opiate, hoping, that if I
"78 INJURIES OF THE HEAD
could procure sleep he might be better. But when I saw the al-
tei-ed appearance of the wound, and found that the pericranium
had quitted its adhesion to the scuIJ, I was no longer in doubt,
that whatever else might concur to disorder him, yet all his com-
plaints were fairly deducible from the effects of his fall. And I
apprehend he owed the preservation of his life to the treatment
he underwent, in consequence of such supposition.
CASE IX.
CONTUSION WITH WOUNDS.
A WATCHMAN, whosc Stand was in White-chapel, got into a
scuffle with some drunken sailors, and received several wounds
and blows on his head; from some of which he lost so much blood,
that he was the next day brought into St. Bartholomew's hospital
in a very weak low state.
Not one of the wounds, which were five in number, had passed
the pericranium, but his whole head was very much swollen and
bruised. He was in other respects very well; that is, he did not
complain of sickness, nor any other kind of pain than what sore-
ness the bruises necessarily occasioned; and he had the full and
perfect use of his senses. As he had already sustained great loss
of blood, and was more than sixty years old, I made use of no far-
ther evacuation, but dressed his head superficially, and directed
that he should be kept in bed. At the end of about a week, the
general tumefaction was nearly gone, and all the wounds in a
healing state; the man transgressed the rules of the hospital by
staying out all night, and was discharged. On the fifteenth day
from that of the accident, he came to me again, complaining of
head-ach, giddiness, sickness, failure of strength, loss of appetite,
and want of sleep.
All the wounds, except one, were perfectly healed; this was on
the upper part of the right parietal bone; it was crude, spongy,
and the exuberant flesh of such colour and consistence, as inclined
me (considering at the same time his general symptoms) to sus-
pect mischief underneath it. I took him into the house again,
FROM EXTERNAL VIOLENCE. 79
«nd immediately removed a circular portion of the scalp, includ-
ing the wound, and found both pericranium and scull in the state
I suspected; that is, the former altered and detached, and conse-
quently the latter bare. Neither the age, habit, nor state of the
man, seemed to be capable of bearing free evacuation, nor did I
in my own opinion believe that there was time for the experi-
ment. I therefore perforated the middle of the bare part of the
bone, and found a sufficient warrant for having so done; that is,
a small quantity of maUer on the surface of the dura mater. His
head was dressed lightly, a little blood was drawn from one of his
arms, and a clyster thrown up to procure a stool. The following
night he passed ill: had a slight shivering, got little or no sleep,
and complained very much of pain in his head; the bare mem-
brane looked very crude, discharged a thin gleet, and pressed
hard against the edges of the bone. The next day, his pulse be-
ing considerably risen, he was let blood again: that afternoon he
had another rigor, and his pain as well as fever became more in-
tense.
On the eighteenth day, finding him in every respect worse, I
made another perforation just below the former, and gave thereby
a discharge to a larger quantity of matter, which the close pres-
sure of the dura mater against the edges of the perforation had
hitherto confined. On the twentieth, he was indeed rather easier,
but his fever was very high, and both the dura mater and sore in
the scalp looked very ill; wherefore suspecting more matter, and
being satisfied the man had no other chance for life, I made a
third perforation close by the second. This procured so large a
discharge of pus, that I was very apprehensive that the extent of
the mischief was too great for the assistance of art to prove effec-
tual in: however, I was happily disa.ppointed: for in a very few
days more, all his bad symptoms gradually left him, and the man
got perfectly well.
From considering all the circumstances of this case, I am satis-
fied, that had not the cranium been perforated at all, the man
must have died, from the collection and confinement of matter:
and I am also as much convinced, that the two former perfora-
tions would have proved insufficient for the purpose, and that the
man owed his preservation to the large removal of bone.
80 LNJUKIKS ur THE HEAD
This is a point of practice, which has by no means been suffi-
ciently attended to by practitioners, nor sufficiently inculcated by
the writers of our country at least. Many, who see and are con-
vinced of the justness and propriety of it, want authority to vindi-
cate them in proposing or executing it; and some part of the dis-
grace which has been cast on the operation of the trepan has
arisen from this cause. Practitioners have in general been afraid to
make more than one opening, and that generally a small one. If
the inflammation be of any extent, or the quantity of matter at all
considerable, this one small opening must prove insufficient, either
for the relief of the tense inflamed membrane, or for the evacua-
tion of the fluid; and the only probable chance which the patient
can have, must be from the removal of a large portion of bone;
and this equally in the case of exiravasation of blood or serum, as
in that of abscess.
CASE X.
CONTUSION JOINED WITH EXTRAVASATION.
A FIREMAN, who was at work on the top of a house, fell in with
the roof of it ; he was taken out senseless, and brought in that
state to the hospital.
He had on diiferent parts of his body several wounds and
bruises, but none of them seemed to be of any great consequence.
On his head were four, one of some size, on the upper part of the
frontal bone near to the coronal suture, two on the left parietal,
one on the right side of his head, just above his ear, and a small
bruise on the upper part of the os occipitis. Of all these wounds,
the pericranium was divided in one only, viz. that near the coro-
nal suture.
His wounds were dressed, he was largely bled, a clyster was
thrown up, and a purging mixture was ordered to be given
cochleatim, until he should have a discharge per anum. The
next day he was in the same slate, perfectly senseless, had the
apoplectic sterior, a full labouring interrupted pulse, and some
difficulty of respiration. He had four or five large stools, where-
KROM EXTERNAL VIOLENCE. 81
fore his mixture was discontinued, but sixteen ounces more of
blood were drawn from one of the jugular veins; which evacuation
was repeated again in the evening of the same day, to the quanti-
ty of eight more. On the third day, being still perfectly stupid,
discharging both urine and faeces involuntarily, and having still a
full labouring pulse, both the temporal arteries were opened, and
fourteen ounces drawn from thence. On the fourth, finding no
alterjition, and being satisfied that the man's state could hardly be
made worse, I determined to perforate the cranium, and ac-
cordingly set a large trephine on the upper part of the frontal bone,
where the pericranium had been divided. The dura mater was
found to be thinly covered with grumous blood, some of which I
removed, and thereby made way for the discharge of more. The
next day (ihe fifth), finding that what discharge had been made,
during the night, was bloody, and that the man was in no respect
altered for the better, I thought I had sufficient authority for re-
peating the operation, which I accordingly did, close by and be-
low the former; and as the blow, by which the wound had been
inflicted, seemed to have been almost exactly on the top of his
bead, I made a third opening in the parietal bone, close to the
suture. The appearance under all was the same as under the
first, viz. a thin layer of grumous, or rather coagulated blood.
Next day (the sixUi), toward evening, the man opened his eyes;
and on the seventh in the morning he spake. The discharge of
blood continued for several days, and at the end of about a week
from this time ceased; the dura mater and the wounded scalp
wearing as good an aspect as could be wished, and the patient be-
ing easy and rational.
On the eighteenth day, he complained of pain all over his
head; was sick, reached to vomit, and said that he was faint
and chilly. On the nineteenth, his face was flushed, his skia
hot, his pulse quick and hard. He was let blood, and ordered to
have a clyster, and to take some medicines of a febrifuge kind. A
day or two more passed in this manner, his fever not violent, but
rather increasing than remitting; his pain, though not acute, yet
such as to deprive him of his sleep; little rigors occurring irregu-
larly, no perspiration, and an excessive 'anguor. At l^ist, on the
twenty-first day, on the upper part of the os occipitis, on the
ve>L. I. L
82 INJURIES OF THE HEAD
right sid€ where there had been a small bruise, a tumor arose, so
characterised, as to satisfy me that the cause of the late alteration
of circumstances lay underneath it: it did not rise to any height,
and contained a small quantity of sanies, but covered a portion
of bone which the pericranium had quitted. I removed the scalp,
and would have set on a trephine, but the man obstinately refused
to submit to it.
On the twenty-fifth day, he lost the use of his left leg and arm,
and was at the same time much convulsed in his right; which
paralysis and spasm continued until the twenty-seventh, and on
the twenty-eighth he died.
Upon examining his head, a collection of matter was found
under the bare part of the occipital bone; the dura mater under
this matter was sloughy and putrid, and about a desert spoonful of
matter lay between the meninges, just under the altered part of
the dura mater. In the part where the bloody extravasation had
been, every thing was perfectly fair and free from disease.
In this case, there seems to have been as clear a distinction be-
tween the bloody extravasation, with its effects, and the inflamma-
tory state of the dura mater, with its consequences, as can be de-
sired. All the first symptoms were such as were caused by mere
pressure of the extravasated blood; an obliteration of every sensi-
ble faculty, attended with the principal symptoms of an interrupt-
ed circulation. Perforation of the scull, where this extravasation
had been made, did, by giving discharge to the blood, happily re-
move these, and the man was getting well apace, until the ills aris-
ing from another cause, viz. the inflammatory secession of the
dura mater in consequence of contusion, and that in another place,
began to appear; they indeed made their attack rather late, nor
did they rise so high as they most frequently do; but then it must
b€ considered what discipline the poor man had undergone, and
what evacuation had been made. Notwithstanding which, they
bore their true, genuine, febrile, inflammatory character, and pro-
duced their most frequent event. What perforation of the os
occipitale might have done, I cannot say; I fear but little, as the
matter was not only upon, but underneath the dura mater, and
that too diseased.
FROM EXTERNAL VIOLENCE, 83
CASE XL
CONTUSION WITH WOUND.
A DRAYMAN, drunk, and sleeping, fell from his dray, and his
liead was so squeezed between the wheel and a post, that a con-
siderable portion of the scalp, together with the pericranium, wag
forced off from each parietal bone.
He was brought to the hospital senseless: he was largely let
blood, and the separated scalp being so bruised and mangled as to
afford no probability of re-union, it was removed, and the bone
dressed with dry lint. The next day the man was so well, and so
perfectly master of what sense he had, that I was inclined to be-
lieve, that a great deal of the last night's appearance was owing
principally to liquor.
In ten days time, the edges of the torn scalp were digested, and
bore all the appearance of sores in a healthy man. One of the
parietal bones seemed disposed to granulate without any exfoliation,
the other looked as if it would throw off a scale.
On the thirteenth day he was so well, that having a large family
to work for, he desired to be discharged from the hospital, and to
be made an out-patient; but his sores were still so large, and I had
so often been deceived by the fallacious appearance of such cases,
that I persuaded him to stay another week.
On the sixteenth day he complained much of head-ach, and
said, that he was sick and chilly; on the seventeenth, the florid,
granulated appearance, and laudable matter of the sores, were ex-
changed for a tawny, glassy surface, and a plentiful thin gleet. I
bled him freely, and bid him keep in bed. On the same day, to-
ward evening, he had a shivering, and, the day following, twa
more; that parietal bone (the left) which had hitherto looked as if
it would be covered by a granulation, without exfoliating, now
wore so diseased an aspect, that I fain would have set a trephine
on it immediately, but the man would not permit me. Every
other means were used, but to no purpose. The sore on the right
side of the head continued to look well, but the scalp quitted its
81 INJURIES OF THE HEAD
adhesion to almost the whole left parietal bone, which bone looked
very unlike to a healthy one.
On the twenty-third day from that of the accident, he died,
having been paralytic in his right leg and arm from the twenty-
first.
The appearance of the two sores, as well as of the two bones,
Avere so different, that I had curiosity to see the state of the parts
underneath each. On the right side, the dura mater was in a na-
tural, sound, adherent state. On the left, it was separated from
almost the whole bone, and covered plentifully by matter, and was,
for about the breadth of a half-crown, sloughy; under the slough
the pia mater was diseased also, and matter was also formed ort
the surface of the brain.
CASE Xli.
The following case was brought into St. Bartholomew's hospital^
while I VMS confined to my house by sickness. The account,
therefore, of the patient, while living, is as taken by Mr. Earle,
(the present Editor) ; and that of the appearance after death, is
in the words of the late ingenious Mr. Partridge, who assisted
Mr. Earle in the examination of the body.
On the tenth of February, 1765, John Biggs, a lad about thir-
teen years old, was driving a horse round a grinding-mill; the
horse not being used to the work, ran round very fast; the boy
fell, and received such a blow from some part of the frame ic
which the horse worked, that he lay, deprived of sense, for some
time, that is, until somebody came in to inquire why the mill
went so rapid. He had a small wound on the right side of his
head, and no other apparent mark of injury. In a few hours, by
the assistance of phlebotomy, he seemed to be very well again.
His wound was dressed by the family apothecary for a week, dur-
ing which time he did not seem to have any other complaint, ex-
cept noiv and then having a slight head-ach. The wound not
Jiealing kindly, the boy, being a country boy, hired only for the
PROM EXTERNAL VIOLENCE. 85
purpose of driving the mill-horse, and the people with whom he
lived being tired of keeping him unemployed, he was brought to
the hospital. The wound was not large, and although he did
pot seem to have any other complaint, was nearly three weeks in
healing.
On the eighth of March, he was seized with a fever, beginning
with a kind of cold fit. On the tenth he was much disordered,
complained of acute pain in his head; and his wound, which had
been healed, broke out again, the pericranium separating from the
bone; on the twelfth, he became senseless to all ouUvard objects,
was convulsed in all his limbs, and jaw-locked. On this day Mr.
Crane trepanned him on the upper, fore and right side of the
frontal bone. On the surface of the dura mater was found a con-
siderable quantity of good matter: on the next morning he died.
The dura mater was detached from the cranium for about an
inch, all round the perforation of the bone; what matter had been
formed on its surface had been discharged by the operation, and
little or none lodged; the pia mater and brain sound in this part.
At about two inches distance from the original wound, higher up,
and nearer both to the coronal a»d sagittal sutures, was a small
tumor about the size of a split garden bean; within this was a very
little discoloured matter, and under it the bone was bare. The
dura mater corresponding with this tumor was detached, black,
and sloughy, and a considerable quantity of matter lay under this
sloughy part, communicating with an abscess formed between
the two hemispheres of the brain, on the right side of the falciform
process.
SECT. III.
SEPARATIOK, OR DESTRUCTION OF BOTH TABLES OF THE SCULL,
FROM CONTUSION.
The separation of a portion of the cranium, consisting of both
tables, or of the whole thickness, happens not unfrequently in old
or neglected venereal disorders. The disease, which in these cases
86 INJURIES OF THE HEAD
has its seat in the diploe, often spoils the whole substance of the
bone, and produces a separation or exfoliation of its whole thick-
ness: the dura mater being always found, in such case, to be co-
vered only by an incarnation generated from its surface.
This kind of caries is sometimes of large extent, in one piece,
but more frequently it is of smaller size," and affects diiferent
parts of the same scull. The separated piece is generally quite
carious, and appears as if it had been worm-eaten, (what the
French call vermoM/owe). The surface of the bone so diseased is
seldom much elevated, though generally somewhat; neither has it
often the circumscribed form and appearance of a true node, as it
is called; though now and then it has.
The scalp, which covers a bone in this state, is most frequently
diseased also; sometimes with one large, ill-conditioned sore; but
more often with a number of crude, foul, painful, serpiginous ul-
cers; through most of which a probe will discover a rough, bare
bone; and from which is constantly discharged a greasy, stinking
sanies. This complaint is generally accompanied by a nocturnal
head-ach, pocky spots, and pains about the breast and shoulders;
and is almost always preceded by the former, though very fre-
quently that symptom ceases, either during the mercurial courses,
instituted for that purpose, or when the pericranium covering the
diseased part becomes foul and sloughy.
The proportion of extent of surface, which one table of these
diseased parts of the cranium bears to the diseased part of the other
table, is very uncertain, and often very unequal. Sometimes the
alteration of the outer table is much more extensive than that of
the inner; in which case, when the separation is made, the de-
tached piece comes away very easily, and the uncovered part of
the dura mater is small, compared to the size of the external sore;
but sometimes, on the contrary, the disease occupies a more con-
siderable extent of the inner table than of the outer, and thereby
renders the case more difficult, and the cure more tedious.
A mercurial course begun even before the scalp covering the
diseased parts shall have been ulcerated, though it be often suffici-
" I iiave seen, in one case, nearly tlip whole os frontale cast off; and, in
another, the whole left parietal bone.
FROM EXTERNAL VIOLENCE. 87
ent fully and perfectly to eradicate the lues from the habit, will
neither prevent nor cure this local malady; which will therefore
often remain, after such cause of it has been really and totally
removed: the bone is thoroughly spoiled (at least in the parts af-
fected); and although the disease, considered abstractedly, be
cured, yet the texture of these harder parts necessarily requires
more time to cast off what is unsound, and to put on a healthy ap-
pearance, than the softer do; the local distemper will remain a
long lime after. An inattention to, or a misunderstanding of this
circumstance, has been the cause why many people have been
harassed, and even destroyed with unnecessary mercurial processes,
when the complaint has been truly local, which it frequently is
after proper previous mercurial treatment. Such medicines will
be found to be so far from hastening the remoA'^al, that, by spoiling
the constitution, relaxing the solids, impoverishing and dissolving
the fluids, and weakening the vis vitae, they prevent nature from
executing her own purpose, and really protract and retard that
effect which they are used (though injudiciously) with design to
expedite. Mercury is undoubtedly a specific for the venereal dis-
ease, but it is itself a poison. It will also cure some other diseases;
but its effects on the human frame are neither light nor superficial.
It becomes beneficial or prejudicial, according to the manner in
which it is applied; and when it ceases to do good, it will most
certainly do harm. This, though a very flagrant instance of it, is
not the only one which might be produced; the same observation
might be made on the maladies proceeding from a diseased pros-
tate and urethra, producing indurations, and fistulas in perineo, in
which the persistance in the use of mercurials, after the producing
lues has been cured, has cost many a man his life, by aggravat-
ing and continuing that symptomatic hectic fever (the necessary
consequence of pain and irritation) which it should be the whole
business of art to calm and attemperate. In all these cases, a
strong decoction of sarsaparilla with milk for the common drink,,
a soft nutritive diet, a clear air, and the free use of the Peruvian
bark, will be found to be more conducive to the patient's reco-
very, than any continued use qf mercury. By the former he will
88 INJURIES OP THE HEAfi
be restored and strengthened, by the latter he will be irritated,
wasted, and destroyed."
* Mr. Potl's remarks on the abuse of mercury are extremely valuable, and
deserve every attention. Much mischief has certainly been ciiused by continu-
ing to give mercury after tlie venereal virus has been subdued. Mr. Pott lias
in this place somewhat deviated from his subject of injuries of the head from
external violence ; but it was principally to shew the similitude between some
exfoliations which are caused by thejvenereal virus, and others which are some-
times the efl'ecl of contusion. That large exfoliations do often happen in
bones which have been affected with venereal virus, is very certain, though,
■without question, they are infinitely less frequent than formerly, the disease
being understood, and more attention being paid to it in its earlier stages. It i$
now, even in hospitals and among the lowest order of persons, very rare to
see a carious scull. However, what has been, again may be. I have certainly
seen, as Mr. Pott observes, exfoliations almost to the extent of the frontal
or parietal bones; but, by judicious management, 1 think this may some-
times be avoided. Exfoliation of bones cannot take place, most particularly
from the cranium, without causing great deformity : it should therefore by
all possible means be prevented. Bones being uncovered, and exposed to
the air, is the great cause of exfoliation ; and this it is the duty of surgeons as
much as possible to avoid. What I would wish to Inculcate is, that though
through an opening in the scalp the probe discovers a bare bone with a rough
surface, it should by no means be uncovered, as I believe has not infre-
quently been practised ; and the admission of air through the small opening
should be as much as possible prevented ; or where there are several open-
ings leading down to the diseased bone, the intermediate skin should be
carefully preserved. If there be reason for suspicion that there still remains
some venereal virus, every means which skill, assisted by mercury, can em-
ploy, should be used to stop the activity of, and eradicate the poison. When
that is done, provided we do not irritate by repeated examinations, or the
introduction of any foreign bod\', the diseased bone will often lie quiet, and
any further destruction or deformity will be avoided.
As this observation appears to me important, I shall endeavour to illus-
trate it by relating a case which occurred several years paSt. I Was sent
foi', to see an unmarried lady in a most respectable family, who had a sore
on her forehead a little above the left eye-brow. On examination with a
a probe, I found the bone bare ; and on insinuating it further, it made its
way over the whole surHice of the os frontis, which was separated from the
scalp, and very rough. The skin covering it was smooth, even, and of a
liealthy natural appearance. There was no other opening or communication
with the bone, except that just mentioned : there were some other tu-
mors or risings on other parts of the head. Considering all these appearances,
which were accompanied with great and frequent pain in the head, I
made no doubt of its arising from venereal poison in the habit. My opinion
gave great olfence, and I was informed that the lady, v^hose purity I had so
boldly arraigned, had been twelve months under the care of the late Dr. F.,
FROM EXTERNAL VIOLENCE. 89
The same kind of exfoliation or separation of both tables of
the cranium, is sometimes the consequence of mere external vio-
lences
The four following examples, which have fallen within my own
knowledge, I shall relate without any comment.
CASE XIII.
A gentleman's coachman was thrown from his box, on the
road between London and Richmond, and received a wound in
his forehead, which divided the pericranium, and denuded the
bone about an inch above the sinus. The man received no other
who, had there been any grounds for my suspicion, must have discovered it.
However, as it was not the first time I had witnessed the Doctor's total igno-
rance of this disease, though in other respects acknowledged by the world
an excellent physician, and as I was well acquainted with the various forms
and appearances the venereal proteus can assume, I would not give up my
opinion; though at the same time I affirmed that the disease might be inno-
cently caught, and mentioned some cases to prove this assertion. I was how-
ever informed that my future attendance would be dispensed with. About a
week after, I was desired to meet Dr. F. and two other physicians, one of
whom was the late Sir Richard Jebb, who, on seeing the case, immediately
pronounced it venereal.
I was now intreated to take care of it, and by the usual means cured the
disease. The pains in the head ceased, the small tumors subsided, and no
exfoliation took place except at the wound, the rest of the forehead remain-
ing perfectly firm, and the skin covering it without further opening or ul-
ceration.
The disease was afterward traced from a woman with whom the lady had
slept, and who had a venereal ulcer, which had probably been in contact
with this unfortunate person in a part, from which the cuticle had been by
some accident abraded. E.
y Morgagni deduces this from mischief done to the vessels of the diploe.
** Antequam de calvaria: ictibus verba facere desinamus, illud non est prse-
" tereundum, utraque ejus tabula prorsus illsesa, illsesisque subjectarum me-
" ningum vasis, accidere aliquando ab ictu valido obtusi corporis, ut vast ula,
" quae inter tabulas meduUse subserviunt, rumpantur, et sanguinem fundantj
"tqui procedente tempore corruptus, eoque acrior factus, quod succos me-
" dullosus admisceatur, qui tum mora et calore, in pessimam degeneret ran-
" cedinem, interiorem tabulam carie afliciat; hominique, jam ictu obliio, et
" nihil ejusmodi timenti, intro defiuens, meninges vitiet necenique afferat."
De Sedibus et Causis, &c.
VOL. I. M
90 INJURIES or THE HEAD
harm in the fall; the lips of the wound were brought together by
suture, and he drove home.
Tiie next day his master, who was a governor of St. Bartholo-
mew's, and a timorous man, sent the patient into that house. As
he seemed perfectly well, and the wound looked as if it would
unite without any trouble, I dressed him only with a superficial
pledget. This did not succeed, and the edges, instead of uniting,
became spongy. I therefore ordered him to be dressed with a
little dry lint, thinking that the bare bone would soon throw off a
small scale, and finish the matter. At the end of three weeks
every thing was exactly in the same state; the bone bare, and not
likely to exfoliate, and the edges spongy. Being in perfect health,
the man was tired of the confinement of the hospital, and was
permitted to go home, taking dressings with him.
At the end of two months from the date of the fall, he returned
to the hospital again, and desired me to look at his sore; which
was not only not healed, but discharged much too large a quanti-
ty of matter. The opening was about the size of a silver tliree-
pence, round, soft, and spongy: upon feeling with a probe, I
thought that the bone receded too much for a mere loose exfolia-
tion, and as the bone receded, the discharge of matter increased.
Upon repeated trials, I was thoroughly satisfied that both these
circumstances were true, and also that the loose piece was much
too large to be extracted from the present opening.
I considered, that the removal of a circular piece of skin would
leave a scar, which would not only be a great deformity, but a
deformity which would be liable to misconstructions; and as there
were no bad symptoms to be obviated, nor any thing to be done,
but merely to remove the loose portion of bone, I made a longi-
tudinal incision, sufficient for its extraction, and laying hold of it
with a pair of forceps, brought it away. It was the whole thick-
ness of the cranium, in every part firm, hard, and perfectly white;
and it left the dura mater covered by a florid healthy incarnation.
I laid the divided scalp down upon the membrane, without any
intervening dressing, and the sore healed in a few days.
FROM EXTERNAL VIOLENCE. 91
CASE XIV.
An elderly woman riding in a hackney landau, by a sudden
jolt struck her head with great violence against an iron hook at
the top of it, put there to hold the two parts of the roof together.
The blow gave her exquisite pain for the instant, but that soon
ceased; and as it caused neither wound nor tumefaction, she took
no further notice of it. At the end of near two months, she was
seized with a violent pain in her head; so violent, that for several
nights she was obliged to have recourse to laudanum, in order to
obtain a little broken rest.
In about a week her pain went off, and a tumor arose, just
where she had been stricken; that is, just in the middle of the
sagittal suture.
Mr. Brown, of Little Britain, had the care of her: with him I
saw her; we opened the tumor, and discharged a considerable
quantity of discoloured and very offensive matter. I passed my
finger into the opening, and to my great astonishment found it
touched the dura mater. We removed a circular piece of the
scalp, and found the two ossa parietalia bare, and carious for a
considerable extent on each side of the suture; and in the middle
of this carious piece, just in the track of the suture, a hole large
enough to admit easily any man's finger, without touching the
edges of the bone.
No exfoliation was found in the matter, or on the membrane;
the dura mater lay at a considerable distance from the scull, in
that part; the discharge from within was large and very offensive;
and about three weeks from the time of opening, she died sud-
denly in a kind of fit.
CASE XV.
In the middle of September 1763, a woman about sixty years
old fell down stairs backwards; she was stunned by the blow
which her head received from one of the steps, and lay senseless
some time.
92 INJURIES OP THE HEAD
There was neither wound nor considerable bruise; she was let
blood, and kept quiet for some few days; at the end of 'which,
finding no inconvenience either general or particular, she ceased
to regard it.
On the eighteenth of December, she was taken into the hospi-
tal, for a swelling on the right side of her head, nearly of the size
of a split Seville orange. This tumor, she said, had been pre-
ceded by a severe head-ach without fever; but as she did not then
believe that her fall had any share in the production of her pre-
sent complaint, she said nothing about it.
Her head being shaved, the tumor appeared full of fluid. I
divided the scalp, and let out a quantity of greasy offensive mat-
ter. Upon further examination, the bone was found to be bare
and carious. I removed such a portion of scalp as brought the
whole into view. The natural texture of the bone was destroyed,
and in it were several holes, through which a probe might easily
be passed, and from which matter was discharged in such manner,
and with such motion, as plainly proved that it came from with-
in the cavity of the scull.
She remained in the hospital until the middle of March ; dur-
ing which time no alteration appeared in any part of the bare
bone.
The affairs of her family now required her to be at home.
She was in perfect good health; was discharged from the hospi-
tal; and as she lived very near to me, one of my young gentlemen
undertook to take care of her. On the twenty-eighth of March,
1764, a small part of the bare bone came away, and left the
dura mater covered by an healthy incarnation; and on the twelfth
of April following, the whole remainder, being about a third
part of the parietal bone, did the same. From first to last she
had no kind of uneasiness, and the sore healed without any
trouble.
CASE ^XVI.
In that ever memorable defence, made by Capt. Gilchrist, ou
board (as I think) the Southampton man of war, against a most
TROM EXTERNAL VIOLENCE. 93
shameful superiority of French force, a sailor received a severe
blow on his head by a large splinter: a small wound and a con-
siderable bruise were the immediate consequence; but they were
so 'soon well, that the man did duty in a few days. At about
seven weeks distance from the time of the accident, he began to
complain of great pain in his head; which pain in a few days
rendered him so incapable, that he was put into the hospital at
Gosport. He remained there about three weeks, frequently but
not constantly in pain; and during that time had three or four
jfits, like epileptic ones.
He was now sent to St. Bartholomew's hospital, and put under
the care of Dr. Pitcairn, by whose order he was bled, purged,
and took several medicines. The man having one day mention-
ied the circumstance of the blow, the doctor desired that I might
examine him.
There was not the least degree of swelling or inflammation, no
mark or vestige of a scar, nor any elevation of the scalp, or fluc-
tuation of fluid, under it. While I was examining his head, he
had a slight attack of spasm; but on my desisting he became
easy and tranquil.
The circumstance of this attack, while I was pressing upon
the part, did not at that instant strike me as worthy notice, but
upon reflection it appeared much so. The next day I made the
same experiment, with the same eflfect; that is, upon hard pres-
sure he became convulsed, which convulsion ceased upon re-
moving the fingers, but was followed by a rigor. On the follow-
ing day I ventured to repeat the experiment; but the man was so
immediately and so terribly convulsed, that J determined never
to try it again.
I informed his physician of all that had passed, and we
agreed, that considering the inefficacy of all that 4iad hitherto
been done, and what had lately happened, the most probable me-
thod of attempting his relief would be, by denuding and perhaps
perforating the cranium, in the place where the pressure produced
so strange an effect.
The next day I removed a circular piece of the scalp, and
found the pericranium not of a healthy or sound colour, nor ad-
herent to the bone; which bone was carious, and had several
94 INJURIES OF THE HEAD
small holes iu it, through which a sanies rose and fell, according
to the motion of the blood in the brain. I applied a large tre-
phine, without any regard to the suture, and removed a piece of
scull. During the time of the operation, the poor man suffered
greatly from spasm; but that over, he became easy and quiet.
The dura mater was detached from the scull, and had matter on
its surface; which matter was extremely offensive. The ensuing
night he passed ill; and the next day had such a rigor, that I
verily thought it was the last trouble the man could have. The
day after this I found him vastly better; the discharge from his
head had been large, but he had not suffered any return eiiher
of spasm or rigor, and his principal complaint was extreme low-
ness.
The physician prescribed for him ; his medicines agreed well
with him, and every thing for several days wore a favourable
aspect. On a sudden he was seized with all the symptoms of a
peripneumony, and, on the third day from that seizure, died. No
apparent cause of mischief was found either within or on the
outside of the head, the dura mater was well incarned, and no
lodgement of matter.
SECT. IV.
FISSURES AND FRACTURES OF THE CRANIUM, WITHOUT DEPRES-
SION.
Fractures of the cranium were, by the ancient writers, di-
vided into many different sorts, each of which was distinguished
by an appellation of Greek etymology, borrowed either from the
figure of the fracture, or the disposition of the broken pieces.
These are to be found in most of the old books; but as they merely
load the memory, without informing the understanding, or
assisting the practitioner, modern authors have generally laid them
aside.
This kind of injury is divisible into two general heads; viz.
those iu which the broken parts keep their proper level, or equality
FROM EXTERNAL VIOLENCE. 96
of surface, with the rest of tlie scull, and those In which they do
not; or, in other words, fractures without depression^ and frac-
tures with.
These two distinctions are all which are really necessary to be
made, and will be found to comprehend every violent division
of the parts of the scull, (not made by a cutting instrument,) from
the finest capillary fissure, up to the most complicated fracture:
for fissures and fractures, differing from each other only in the
width of the breach, or in the distance of the separated parts, and
the disposition of broken pieces in large fractures being subject to
an almost infinite variety, distinctions and appellations drawn and
made from these circumstances might be multiplied to even three
times the old number, without imparting the smallest degree of
useful knowledge to the man who should be at the pains to get
them by heart.
What are the symptoms of a fractured cranium.'* is often asked;
and there is hardly any one who does not, from the authority of
writers, both ancient and modern, answer, vomiting, giddiness,
loss of sense, speech, and voluntary motion, bleeding at the ears,
nose and mouth, &c. This is the doctrine of Celsus, which has
been most invariably copied by almost all succeeding authors, and
implicitly believed by almost all readers.^
The symptoms just mentioned do indeed very frequently ac-
company a broken scull, but they are not produced by the breach
made in the bone; nor do they indicate such breach to have been
made. They proceed from an affection of the brain, or from in-
jury done to some of the parts within the cranium, independent of
any ill which the bones composing it may have sustained. They
are occasioned by violence offered to the contents of the head in
general; are quite independent of the mere breach made in the
bone; and either do or do not accompany fracture, as such
fracture may happen to be or not to be complicated with such
other ills.
^ " Igitur ubi percussa est calvaria, protinus requirendum est, num bilem
"is homo vomuerit, num oculi ejus obcsecati sint; num per nares, uuresve
"sanguis ei efHiixerit; num conciderit; num sine sensu quasi dormiens
"jacuerit? &c. hsc enim non nisiossefrcicto eveniunt."
&6' INJURIES OP THE HEAD
They are frequeatly produced by extravasations of blood, or
serum, upon, or between the membranes of the brain; or by
shocks, or concussions of its substance, in cases where the scull is
perfectly entire and unhurt. On the other hand, the bones of the
scull are sometimes cracked, broken, nay even depressed, and the
patient suiTers none of these symptoms.* In short, as the breach
made in the bone is not, nor can be the cause of such complaints,
they ought not to be attributed to it; and that for reasons which
are by no means merely speculative. For the practitioner, who
supposes that such symptoms do necessarily and certainly imply
that the cranium is fractured, must regulate his conduct by such
supposition, and remove the scalp, very often without either neces-
sity or benefit; that is, without discovering what he looks for: and,
on the other hand, if he does find the scull to be broken, believing
all these complaints to be caused by, and deducible from the frac-
ture, he will most probably pay his whole attention to that sup-
posed cause, and may think, that when he has done what the
rules of his art prescribe for such case, he has done all that is
in his powder — an opinion not infrequently embraced; and which
has been the destruction of many a patient. For, as on the one
hand, the loss of sense, speech, and voluntary motion, as well as
the hagmorrhage from the nose, ears, &c. are sometimes totally
removed by, or at least disappear during the use of free and fre-
quent evacuation, without any operation on the scalp or scull; so
on the other, as these symptoms and appearances are not produc-
ed by the solution of continuity of the bone, they cannot be reme-
died by such chirurgic treatment as the mere fracture may
require.
a " Si Ixsiis instar dormientis sensus expers deprehendatur ; si oculi ejus
*' obcaccati fuerint ; si obmutuerit ; si bilem vomuerit ; si animalis instar
" malleo icti concideiit ; hrec omnia maximam et subitaneam significant cere-
" bri commotionem, pertiirbationein, ac concussionem qiite no7i rara integro
" maneiite, nee vlla ex parte rupto cramo, mortem percusso adferunt."
Pet. Paaw.
" Dans les playes de lete, les accidens que les auteurs anciens ont appelles
" primitifs, parcequ'ils arrivent dans I'instant meme de la blessure, ne sont
" nullcment des accidens, ni des signes, de la fracture subsistante, mais des
"accidensj & des signes, de la commotion de cerveau."
Le Dbak.
FROM EXTERNAL VIOLENCE. 97
If any one doubt the truth of this doctrine, I would desire him
to consider the nature, as well as the most generally successful
method of treating these symptoms; and, at the same time, to re-
flect seriously on the operation of the trepan, as practised in simple,
undepressed fractures of the scull.
' The sickness, giddiness, vomiting, and loss of sense and motion,
can only be the consequences of an affection of the brain, as the
common sensorium. They may be produced by its having been
violently shaken, by a derangement of its medullary structure, or
by unnatural pressure, made by a fluid extravasated on its surface,
or within its ventricles; but never can be caused by the mere
division of the bone, (considered abstractedly,) which division, in
a simple fracture, can neither press on nor derange the structure of
the parts within the cranium.
If the solution of continuity in the bone be either produced by
such a degree of violence, as hath caused a considerable disturb-
ance in the medullary parts of the brain, or has disturbed any of
the functions of the nerves going off" from it, or has occasioned a
breach of any vessel, or vessels, whether sanguine or lymphatic,
and that hath been followed by an extravasation, or lodgement of
fluid, the symptoms necessarily consequent upon such derange-
ment, or such pressure, will follow; but they do not follow be-
cause the bone is broken; their causes are superadded to the frac-
ture, and although produced by the same external violence, are yet
perfectly and absolutely independent of it; so much so, that, as I
have already observed, they are frequently found where no frac-
ture is.
The operation of the trepan is frequently performed in the case
of simple fractures, and that very judiciously and properly; but it
is not performed because the bone is broken, or cracked: a mere
fracture, or fissure of the scull, can never require perforation, or
that the dura mater under it be laid bare; the reason for doing this
springs from other causes than the fracture, and those really inde-
pendent on it. They spring from the nature of the mischief which
the parts within the cranium have sustained, and not from the ac-
cidental division of the bone. From these arise the threatening
symptoms; from these all the hazard; and from these the necessity
and vindication of performing the operation of the trepan.
VOL. I. N
98 INJURIES OF THE HEAD
If a simple fracture of the cranium were unattended in present
with any of the before-mentioned symptoms, and there were no
reason for apprehending any otlier pvil in future, that is, if the so-
lution of continuity in the bone were the whole disease, it could
not possibly indicate any other curative intention, but the general
one in all fractures; viz. union of the divided parts. But how can
such union be promoted or assisted by perforation? it most cer-
tainly cannot; and yet perforation is absolutely necessary in seven
cases out of ten, of simple undepressed fractures of the scull. Let
us for a moment inquire why it is so. The reasons for trepanning
in these cases are, first, the immediate relief of present symptoms
arising from pressure of extravasated fluid; or second, the discharge
of matter formed between the scull and dura mater, in consequence
of inflammation; or third, the prevention of such mischief, as ex-
perience has shown may most probably be expected from such kind
of violence oifered to the last-mentioned membrane These are
the only reasons that can be given for perforating the scull, in the ,
case of an undepressed fracture; and very good and very justifiable
reasons they are, but not drawn from the fracture.
In the first case (that of an extravasated fluid within the cra-
nium), the relief from perforation is not only sometimes imme-
diate, but frequently is not attainable by any other means. This
is a sufficient proof, not only of its utility, but of its necessity.
In the second, of formation of matter (between the scull and
dura mater), it is the unicum remedium; there is no natural outlet
by which such matter can escape; and the only chance of life is
from the operation.
In the third, that of mere fracture without depression of bone^
or the appearance of such symptoms as indicate commotion, extra-
vasation, or inflammation, it is used as a preventative, and there-
fore is a matter of choice, more than immediate necessity.
Many practitioners, both ancient and modern, have therefore
disused and condemned it; and have, in cases where there have
been no immediate bad symptoms, advised us to leave the fracture
to nature, and not to perform the operation as a preventative, but
to wait until its necessity may be indicated by such symptoms as
may both require and vindicate it. This is a point of the ut-
FROM EXTERNAL VIOLENCE. 99
most consequence in practice, and ought to be very maturely
considered.
They who object to the early use of the trephine, speak of it as
being frequently unnecessary, and as rendering the patient liable
to several inconveniences which may arise from uncovering the
dura mater, before there is any good, or at least any apparent
reason for so doing. And, in support of this their opinion, they
allege many instances of simple fracture which have been long
undiscovered, without being attended with any bad symptoms;
and of others which, though known and attended to from the first,
have done very ipvell without such operation.
They who advise the immediate use of the instrument do it
upon a presumption, that, in considerable violence received by the
head, such mischief is done to the dura mater, and the vessels by
which it is connected to the cranium, that inflammation of the said
membrane must follow; which inflammation generally produces a
collection of matter, and a symptomatic fever, which most fre-
quently baffles all our art, and ends in the destruction of the pa-
tient.
What the former assert is undoubtedly sometimes true. There
have been several instances of undepressed fractures of the scull,
which, either from having been undiscovered at first, or neglected,
or having been under the care of a practitioner who had disliked
the operation, have done very well without it. This is certainly
true, but is not sufficient to found a general rule of practice upon:
in matters of this sort, a few instances are by no means sufficient
to establish a precedent: what has been, or may accidentally prove
beneficial to a few, may be pernicious to the multitude: that
which is found to be most frequently useful, is what we ought to
abide by, reserving to ourselves a liberty of deviating from such
general rule in particular cases.
This is one of those perplexing circumstances, which all writers
lament, and all practitioners feel, but which, instead of merely
complaining of, we should endeavour, as much as in us lies, to
correct.
In order to obtain what information we can on this subject, we
should consider, first, what the mischiefs are which may most pro-
bably be expected to follow, or which most frequently do follow.
100 INJURIES OP THE HEAD
when perforation has been too long defended, or totally neglected;
secondly, what prejudice or inconvenience does really arise from,
or is thought to be caused by the operatibn itself, considered ab-
stractedly; and thirdly, what proportion the number of those who
have done well without it, bears to that of those who may truly be
said to have been lost for want of it, or of those to whom it might
have afforded some chance of relief.
With regard to the first, I have already observed in the case of
simple undepressed fractures, whenever the trephine is applied, it
must be with design either to relieve, or to prevent ills arising
from other mischief than the mere breach in the bone; which
breach, considered simply and abstractedly, can neither cause
such ills, nor be relieved by such operation. Oiie, and that the
most frequent of these mischiefs, is the inflammation, detach-
ment, and suppuration of the dura matter, and consequently the
collection of matter between it and the scull; a case, of all others
attending wounds of the head, the most pressing, the most hazard-
ous, and the least within our power to relieve. On this subject I
have expressed my sentiments so much at large, under the pre-
ceding article contusion, that it is needless to repeat them here. I
shall therefore take the liberty of referring the reader back to
that, and only remind him of a circumstance well worth his attend-,
ing to; viz. that there are no immediate or early marks or symp-
toms, whereby he can certainly know, whether such kind of mis-
chief is done or not; and that, when such complaints come on as
indicate that such mischief has been received, although the opera-
tion is all that is in our power to do, yet it is very frequently un-
successful.'' Indeed, the only probable method of preventing this
•» The state of the dura mater, under simple fractures and fissui'es of the
cranium, has been very nicely observed, and very justly described, by some
of the best writers of antiquity.
" Si ad cerebri membranam usque pervenerit fractnra, non redemus, sed
" agnoscere conabimur utrum membrana ab osse recesserit, an affixa perma-
" neat. Si enim ipsa manet, inflammatio nulla infestat vulnus, etpus coc-
•• turn apparet. Si cesserit membrina, augeiitur dolores, et febris similiter;
" OS alium sumit colorem ; pus tenue, et crudum eff'ertur ; et si medicus ne-
" gligenter rem tractat, nee perforatio?ie ulitur, hoc graviora symj)tomata
"aboriuntur; nempe bilis voinitus, convulsio, mentis delirium, et febris
"acuta." Paclvs jEcfiK;;;TA,
PROM EXTERNAL VIOLENCE. 101
evil seems to be, the removal of such a part of the scull, as by be-
ing broken appears plainly to have been the part where the vio-
lence was inflicted; and which, if the dura mater becomes in-
flamed, and quitting its connexion suppurates, will, in all probabi-
lity, cover and confine a collection of matter for which nature has
provided no outlet. This I take to be, not only the best, but the
only good reason, for the early use of the trephine in simple unde-
pressed fractures of the scull: and I must add, that it appears to me
to be fully sufficient to vindicate and authorise it. That it frequently
fails of success is beyond all doubt; the extent and degree of the
mischief being too great for it to relieve: but that it has preserved
many a life, which must have been lost without it, I am as well
satisfied of, as I am of any truth which repeated experience may
have taught me.
In matters of this sort, positive proof and conviction are not in
our power; all that we can do is, by making a comparison of
the conduct and event of a number of similar cases, to come as
Hear to truth as we can, and to get probability on our side.
The second consideration which I proposed to be made was,
what mischief or inconvenience may most reasonably be supposed
to follow, or to proceed from the mere operation considered ab-
stractedly. They who are averse to the use of it, as a preventative,
allege that it occasions a great loss of time; that it is frequently
quite unnecessary; and, that the admission of air to the dura
mater, as well as the laying of it bare, is necessarily prejudicial.
The former of these is undoubtedly true; a person, whose scull
has been perforated, cannot possibly be well (that is, cured) in so
short a space of time, as one who has not undergone such opera-
" Dico debet dari signum fractura, a qua removeatur pafiniculus grossus.
" In primo debes scire dispositionem syphs ; utnitn est adherens, an non ; vi-
" delicet, si ad!i?eserit ossi non fiet in viilnus apostema calidum ; et licet ac-
" cidit, modicum erit; senigo manabit de eo modica; et putredo erit di*
" gesta. Sed si faerit remotus, vehementiores erunt dolores, et febres, mu-
" tabitur color ossis, et corrumpetur, et manebit de eo putredo tenuis."
Rhazes.
" Si rinia sit in superficie, cerebri membrana non abscedente, eadem ad-
" hibeatur, qiije ad os nudatum demonstrata est : cerebri vero membrana ab-
" scedente, et humore ibi collecto, post primos cnrationis dies ad terebram
" properandum est," &c^ jDbtbasit-s,
102 INJURIES OF THE HEAD
-tion; supposing such person to have sustained no other injury than
-the mere fracture : and if the majority of the people whose sculls
are broken were to sustain no other iiijury, that is, if no oiher
mischief were in these cases in general done to the parts con-
tained within the scull, the objection to perforation would be real
and great, and the operation a matter of more serious considera-
tion. But this is seldom, too seldom the case; by much the larger
number of those who suffer a fracture of the scull are injured
with regard to other parts, and labour under mischief of another
kind, additional to the fracture; that is, the parts within the cra-
nium are injured as well as the cranium itself. This being the
case, the loss or waste of a little time ceases to be an object of so
;great importance. The hazard which it is supposed may be in-
curred from laying bare the dura mater, is indeed a matter of
some weight, so much so, that it certainly ought not to be done,
but for very good reasons; and yet, although I am clearly of this
opinion, I think that I may venture to say, that, let the supposed
hazard be what it may^ it cannot in the nature of things be by
any means equal to that which mu^ be incurred by not doing it,
when such operation becomes necessary. In short, if we would
form a right judgment of this point, the question concerning it
ought to stand thus: Is the chance of ill which may proceed from
merely denuding the dura mater, equal to that of its being so hurt
by the blow, as to inflame and suppurate? Or is the mischief
which may be incurred by mere perforation of the scull, equal to
the good which it may produce? These questions, let those who
have seen most business of this kind, and who are therefore the
best judges, consider and determine. For my own part, I have
no doubt, that although, by establishing it as a general rule to per-
forate in all cases, some few would now and then be subjected to
the operation, who might have done very well without it; yet, by
the same practice, many a valuable life would be preserved, which
must inevitably be lost without it, there being no degree of com-
parison between the good to be derived from it, when used early,
as a preventative, and what may be expected, if it be deferred till
an inflammation of the dura mater and a symptomatic fever
make it necessary.
PROM EXTEraMAL VIOLENCE. 103
The third consideration, viz. what proportion the number of
those who have escaped without the operation bears to that of
those who have perished for want of it, is in great measure in-
cluded in the two preceding; at least the determination of them
must also determine this.
My own opinion must, till I find reason to alter it, be the rule
of my own conduct; and though I would not by any means
pretend to obtrude the former on any one, yet I think it in some
measure incumbent upon me in this place to give it.
The number of cases of this kind, which are necessarily brought
into a large hospital so situated as Bartholomew's is, in the midst
of a populous city, where all kinds of hazardous labour are
carried on, has enabled me to make many observations on them;
and although I have now and then seen some few of them do well
without the use of the trephine, yet, the much greater number,
whom I have seen perish with collections of matter within the
cranium, who have not been perforated, and from whom there is
no other relief in art or nature, has, 1 must acknowledge, ren-
dered me so very cautious and diffident, that although I will not
say, that I would always and invariably perform the operation in
every case of simple fracture, yet the case must be particularly
circumstanced, the prospect much fairer than it most frequently^
is, and my prognostic delivered in the most grounded apprehen-
sive manner, when I omit it. I should be sorry to be so misun-
derstood, as to have it supposed that I mean to say, that I think
the denudation of the dura mater a matter of absolute indiffer-
ence, or that no ill can proceed from it; this, I know, is a point
concerning which the best practitioners have differed, and con-
cerning which we still stand in need of information; but T think I
may venture to say, what is fully to my present purpose, viz. that
enlarging the opening of a fracture, by means of a trephine, will
not produce or occasion much risk or hazard, additional to what
must be occasioned by the fracture itself, that has already let in
air upon the membrane,'' and therefore that consideration is, at
' It is to be remarked, that Mr. Pott has in this place been speakingof sim-
pie fractures of the cranium without depression, in which he appears inclin-
ed to recommend the use of the trephine as a preventative. I must confess
104 INJURIES OF THE HEAD
least in some degree, at an end; and the principal point to be de-
termined still remains the same, viz. whether, upon a supposition
that the dura mater rnaj possibly not have been so injured as to
inflame and suppurate in future, the operation ought not to be
practised as a preventative, but, on the contrary, ought rather to
be deferred until worse symptoms indicate the necessity of it? or
whether it ought in general to be performed early, in order, if pos-
sible, to prevent and guard against very probable, as well as very
terrible mischief?
I know that it may be said, that a fracture, if of any consider-
able size, or whose edges are fairly distant and unconnected, will
of itself make some way for discharge from within; and so it cer-
tainly may, and does, in the case of an effusion of fluid blood; but
even in this it very seldom proves sufficient for the purpose. But
does not the distant separation of the edges imply greater separa-
tion of the attaching vessels of the dura mater? and does not ex-
perience too often prove this to be the case? In truth, the great
advantage which is sometimes derived from considerable frac-
tures, is most frequent in those cases where portions of bone are
so loose as to be removeable, which removal of bone stands in
place of perforation, and makes much more for the necessity of
the operation in other cases than against it, if properly consi-
dered.
I may possibly be told, that Hildanus Wiseman, arid others of
great and deserved reputation, have been of the former opinion.
I know they have; and when I differ from these, or any other
I cannot clearly perceive how a simple crack or fissure through the scuU
can be said to let in air upon the membrane; or, if it did, that it should be a
reason for uncovering a greater part of it.
If I may take the liberty, after such great autliority, to offer my opinion, I
must say that I do not think the operation with the trephine is to be con-
sidered of lightly. If the injury which has been received be sufficient to
produce mischief, we are by no means certain of finding the seat of it, nor of
preventing it by making an opening. I am therefore decicl^dly against ap-
plying the trephine after every simple fracture or fissure, and think it better
to defer the operation, till some symptoms indicate the necessity of it. This
opinion is drawn from reasoning on the subject, and is confirmed by the
many cases of simple fracture which I have known got well without any
such operation. E.
PROM EXTERNAL VIOLENCE. 105
good authority, I hope that I shall always do it with caution and
diffidence; but I hope also, that I shall never hesitate to differ from
any and every authority, when I think that I have truth on my
side, and the good of mankind in my view. The above-mentioned
writers, together with almost all their contemporaries, had, in
simple fractures of the scull, but one contemplation, the extrava-
sation of blood; this they regarded as the cause both of the early
symptoms and of the late ones; considering it as acting either by
pressure or putrefaction; and therefore, when there was no im-
mediate sign of such extravasation from the effects of pressure,
they saw no necessity for early or immediate perforation. But
had tUey not forgotten the universal adhesion of the dura mater to
the cranium; had they not, without any, or indeed contrary to all
authority from anatomy, formed to themselves an erroneous idea
of the disposition of those parts, with regard to each other;^ had
they conceived rightly of the consequences of an inflammation and
detachment of that membrane, I am much inclined to believe, that
they would have altered their opinion, and not in general have
left penetrating fractures of the scull to nature; although they
had, in some measure, the authority of Celsus for so doing.^
^ Some of the writers of this time speak of the supposed vacuity between
the dwra mater and scull, as being calculated for the reception of extravasated
fluid, in case of accident : which opinion reminds me of that of a much later
writer, who says, *• that the os unguis was made so thin, for its more easy
'' perforation in the operation of the fistula lachrymalis."
" " In omni vero fisso fractove osse, protinus antiquiores medici, ad ferra-
" menta veniebant quibus id exciderent. Sed multo melius est ante em-
" plastra experiri, quae calvarise causa componuntur," &c.
Celsus.
Whoever has an inclination to amuse himself with the different opinions of
different writers on the subject of perforating, or not perforating, will find
them in Palfyn, Rohalt, and many others.
But that the frequent ill effects of neglecting this operation were not un-
attended to by many, the following quotation, taken from a number of simi-
lar ones, may evince :
" Et scias, sicut volunt veteres, quod non est excusatio ab incisione, et re-
" motione cranii, cum in eo penetrans fractura sit ; et hsec propter duo ;
" primo quod os capitis, sicut dictum est, debilem facit porum. Secundo,
" quia si, osse jam restaurato, acciderit interius (quantocunque modice) gene-
" ratio saniei, vel alicujus humoris superflui expellendi, quomodo, jam restau-
" rato osse, posset expelli," &c.
VOL. I. 0
106 INJURIES OF THE HEAD
Before I enter upon the account of the present and most proper
method of treating simple undepressed fractures of the scull, it
may perhaps be not amiss to make a short inquiry into the opi-
nions which our remote ancestors have delivered down to us on
this subject, to take a cursory view of their intention and conduct,
and to examine whether the difference between their practice and
ours be well grounded or not; it being neither antiquity nor no-
velty, but utility only, which can demand our regard.
That extravasation of blood, and formation of matter between
the scull and membranes of the brain, were the two principal
causes of bad symptoms and of death in fractures of the cranium,
and that the only rational method of obtaining relief in either case
was by making such an opening in the bone as would give dis-
charge to the said fluids, was full as well known to our ancestors
as to us. Their intention and ours, therefore, were essentially
alike; and the material difference between our conduct and theirs
consists in the manner in, and the instruments by, which we en-
deavour to execute such intention. When the breach in the bone
was small, and no symptoms of immediate extravasation attended,
their principal apprehension was, that the sanies, or matter, which
they supposed must necessarily be excreted from the edges of the
fracture, would drop down, lodge, and be collected on the surface
of the dura mater.
To prevent this evil, they endeavoured to enlarge the fracture
by abrasion of its edges, by means of scalpra, or rugines. These
scalpra were many in number, and various in their size and figure,
according to the opinion or whim of the practitioner. Figures of
these are to be seen in many writers; in Andreas a Cruce, in Scul-
tetus, in Fabritius ab Aquapendente, in Berengarius, &c. &c. &c.
"Primum notabile est istud, quod in fractura cranii debes prohibere apos-
" tema, ne accidat in cerebro aut in panniciilisj he. Tertium, notabile sit
"is'ud; quod si intentio medici solum esset, in occupatione solutionis con-
"tinuitatis, vel fracturs, stante apostemate, multa mala accidentia possent
'*consequi, utcorruptio panniculi febris, apoplexia, rigor," &c.
Bf.htapal.
* " Ex fracturis vero quae ad cerebri membranas pei-venerunt, si simplex
" fractura sit, angustis scalpris utendum ; sin cum contusione aliqua, quod
"contusum est excidi debebit ; idque vel terebellis prius in circuitumfora-
" turn, ac mox scalpris admotis, vel protinus ab initio cyeliscis."
Galen.
FROM EXTERNAL VIOLENCE. 107
But whoever examines them, and attends to their proposed use.
will find them liable to great objection ; he will find that the use
of them must be irksome to the patient, tedious to the operator,
and unequal to the end proposed. That by such kind of instru-
ment the opening of a small fracture may be enlarged, is beyond
all doubt; but if the breach be at all large, or of any length, such
method of enlarging it must at best be a very operose one; it must
jar and shake the patient's head immoderately; if executed un-
skilfully, or inattentively, it must be attended with hazard of
wounding the dura mater; and when finished, could not properly
answer the purpose for which it was designed.
Of these defects, some of the practitioners were in some measure
sensible; and therefore, when the fracture was of such size, or so
circumstanced, that these scalpra abrasoria would most probably
prove insufficient, that is, when the accident was produced by
such force, or attended with such degree of contusion, as to render
it probable that the parts within were injured, they did not then
depend upon this method by abrasion, but had recourse to others
by which they removed a portion of the cranium.^ In the execu-
tion, of this purpose, also, they found themselves subject to many
inconveniences, arising partly from the awkward and unmanage-
able form and make of their instruments, and partly from the inar-
tificial manner in which they applied them.
Terebrae, and terrebellae, of various sorts, figures and sizeis, the
cycliscos, or scalper excisorius, and a variety of modioli were in-
vented, and used for this purpose, figures of which may be seen in
Vidus Vidius's Comment on Hippocrates de vuln. capit.; in Peter
Paaw on the same; in Andreas a Cruce's Officina; in Albucasis
and others.
When the piece of bone intended to be removed was larger
than could be comprehended within the modiolus then in use, and
which was a very defective instrument in many respects, the ope-
ration was performed by means of terebrae; which operation was
g " In lis quze usque ad cerebri membranam divisa sunt, si sola rima sit,
" iisdem radulis utendum ; si collisio aliqiia una sit, terebris exscindere colli-
" sum oportet, scalpris adhibitis."
Okibasius.
108 INJURIES OP THE HEAD
still more coarse, more fatiguing, and more hazardous than that by
the mere scalpra.
The piece intended to be taken away was surrounded with per-
forations made at small distances'' from each other, and then either
the scalper excisorius or the scalprum lenticulatum was introduced,
and, by means of repeated strokes with a heavy mallet, Avas driven
through all the interspaces between each perforation. By these
means the portion of bone so surrounded was removed, and the
dura mater was laid bare. The tediousness which must attend
the making so many perforations, the disturbance given to the
patiejit's head, as well by the terebra, as by the mallet and chizel,
^ " Ministri juxta assideant, quorum uinis caput Ixsi contineat, alter, oppor-
*'tuna ministeria faciat. Aurium foramina lana coacta obturanda sunt, ne
"sonitu in excisione terreatur. His factis, infigendus calvarije est mucro acutus
" terrebrje ; qua laesum os colorem mutavit, juxta integrum ; deinde lente
" habena terebram convertere debemus, donee inciso ossi mucro insistat ; ac
" turn citatius circumagere oportet habena terebram convertente, donee mu-
" cro in spatium inter duplex os descendat ; ubi autem foramen altius adaetum
" sit ultra crassitudinem spatii inter duplicem testam ossis quod perforatur,
*' turn terebra multo eircumspectius convertenda est, ne repente descendens
" cerebri membranam violet. Cum jam terebra adacta fuerit, ut vel con-
"jectura deprehendatur totam ossis crassitudinem esse perforatam, vel per-
" parum solids sedis infra relictum, tunc is qui operatur, altitudinem de-
" gustet demissa tenuis acus obtusa parte ; ac si quid continuse sedis etiam
" reliquum sit, deprimendus altius terebrse mucro est, eaque lente circu-
*' macta, solidum os perforandum. Eadem quoque facienda sunt in aliis
" foraminibus, donee rima in ambitu perforata sit. Septa vero media inter
"foramina satis habent spatii, fere quantum specilli augusti aversa pai's est.
"Factis foraminibus, turn ad excisionem, qux dicitur, veniendum est, ut ex-
•'cisis turn foraminibus turn mediis, laesa ossa removeantur."
Oribasius.
■ " Modus autem perforationis est, ut figas unum trypanorum (terebarum)
"super OS in circuitu, et revolvas ipsum intra manus tuas, donee scias quod
*• OS terebratum est ; deinde fiat permutatio ad alium locum : et sic permu-
"tatio fiat usque ad ultimum necessitatis. Deinde cum alio instrumento,
"quod dicitur spatumen, ab uno foramina usque ad aliud os incidatur," &c.
Bbunus Cliir. J\fag.
"Pone trypanum supra os circa scissuram, ubi vis foramen facere, et re-
" volve ipsum intra manus tuas donee penetret ; deinde muta ipsum ad alium
"locum, et sic fae tot foramina, quot suffieiant; deinde pone spatumen in
" uno foraminum, et levando manum, superius incidatur terminus, qui est
" inter foramen et foramen, et fac sic donee separatur os totum."
Bhun. Chir. Part.
FROM EXTERNAL VIOLENCE. 10.9
the hazards of wounding the membranes of the brain, and the
coarseness and unhandiness of the whole process, are too obvious
to need a comment.'
Of this most of them were sensible; they felt the inconve-
niences, and dreaded the danger so much, as to run into great ab-
surdities, merely to avoid them. They found that they not only
wounded the dura mater, but sometimes the brain itself; and
therefore had recourse to such precautions, as they thought most
likely to prevent these evils. By some we are advised, not to
make the perforation quite through the bone, but to endeavour to
leave a thin lamina of it entire. By others, to leave the piece,
which the modiolus or terebra had surrounded, adhering to the
dura mater, to be cast off by its suppuration, lest the hasty de-
tachment of it should be mischievous.''
' " Quod vero per cycliscos opus administratur, ne id quidem omnino vitio
" caret, quum quatiat immodice caput, quod potius quietem postulat."
Galen,
" At quae per terebellam ratio quidem fungltur, parum tuta est, propterea
" quod dum audacius earn tractant, duram meningem non raro violant."
Galen.
" Ssepe scalpros pulsantes adeo ut totum cerebrum permoveatur."
Galen.
" Acuta terebra quamplurimas angustas perforationes, cranii fracturas am-
"bientes, radioli crassitudine equidistahtes formare solent; quod vero inter
"foramina residet, aut recti s, aut curvis scalpris malleolo plumbeo adactis
*' rescindere expedit. Lenticulato scalpro, adacto malleolo, id fieri potest^
" horridus tameu quidem modus est, ac in opere tardus."
♦' Scalpra hsec omnia citra malleoli operam nullius momenti sunt ; moventur
" necessario malleolo adacto, prxsertim in rimis, quae ad diploidem usque
" pertingunt ; excavant totum os, ford adhibita percussione, non into sed in-
" commode."
Andiieas a Cruce.
" Malleus ad percutiendum lenticulatum debet esse de plumbo ut in parva
" quantitate magis ponderet."
GUIBO.
" Cavere oportet ut in terebellee admotione, ne falleris, verum qua parte
"crassissimum os esse visum fuerit, in earn semper terebellam admotam
" adigito."
HiPPOCEAT.
" Saepe accidit, ut terebree repente adactx, ob naturalem perforatorum
" ossium-debilitatem, vel tenuitatem, membranam sauciarint."
Oribasius.
'' "Quod si statim initio vulneris inflicti,. curationi adhibearis, 09 ad mem-
no INJURIES OF THE HEAI)
The cautions laid down by Hippocrates, and others, concerning
the part of the bone whereon to fix the instrument, and the great
attention which they admonish the operator to pay to its execu-
tion, all proceed from the same fear. For the same reason, or
from the same well-grounded apprehension, it will be found that
many of the best practitioners endeavoured to furnish their perfo-
rating instruments with such guards or defences as should prevent
them from going too deep.'
In Albucasis, in Andreas a Cruce, and many others, are figures
and descriptions of modioli, duabus, tribus, vel quatuor alis mu-
" branam usque simul et semcl exsclndere non oportet, &c. Prseterquam
" quod aliud subest periculum, si stutim ad membraiiam usque auferas, ne
" inter operandum membranam lacdas. Sed inter secandum id observaio, ut
" postquum eo res perducta, ut parum absit quin unlversum os pertusum sit,
" jamque os vacillare incipit, ab ulteriore sectione abstineas, ossique, ut
" sponte porro secedat, permittas. Namque ossi, quod sectum est, et sine
" exsectione relictum, niliil detrimentl accidere potest."
" Cum itaque terebrje occurrit usus, si statem cui-ationi adhibearis, cavesis
" ne ad membranam usque penetrat, verum portio ossis tenuis relinquenda."
HiPPOCIlAT.
1 " Terebellis autem ipsis, ut mergi non possunt supra cuspidem, nonnulli
" superciliiira extans efiiciunt."
Galen.
" At quia dum terebrum hoc circumagitur, periculum imminet ne mem-
" brana; Isdantur, ideo nonnulli quo minus aberrarent, et iioc periculi genus
" evitarent, terebras excogitarunt qu?e mergi non possunt, et ob id a Greecis
" abaptista dicuntur."
Ajtdreas a Cruce.
*' Si autem os forte durem est, tunc oportet ut pertbres in circuitu ejus
" antequam administres incisoria cum terebris, quae nominantur terebrae non
" profundantes ; et non nominantur ita, nisi quoniam ipsae non pertranseant
" terminum ossis, ad illud quod est post ipsum, propterea quod terebro est
" extremitas rotunda super illud, quod est sub capite ejus acuto, similis mar-
" gini, et circulus parvulus prohibet submergi et pertransire spissitudinem
" ossis. Et convenit tibi, ut accipias ex istis terebris numerum mukum, quo-
" rum unum quodque conveniat quantitati spissiludinis ossis, donee prsesens
" sit tibi omni cranio terebrum," &c.
Albucasis.
" Modiolus fuit veteribus duplex, estque etiamnum hodie vulgaris, turn et
" qui duplicem liabet orbem, alterum supra alterum extantem. Hie abuptis-
"tos Graecis; facit namque orbis sive limbus extans ne profundius mergi
" queat. Hunc itaque describit Galenus 6. meth. cap. 6. Quidem autem quo
" minus aberrarent, tales terebellas excogitarunt quae mergi nequeant, quas
" inde abaptista vocant. Circomcurrit enim parum, supra terebellcC super-
PROM EXTERNAL VIOLENCE. Ill
niti, of those, as well as of terebcllac, called abaptistai, mespilata;,
tortulatae, &c.: the number and variety of these are very large, al-
though they are all formed upon the same principle, and all calcu-
lated for the same purpose, viz. to perforate the scull without
wounding the membrane underneath. But whoever will consider
the very different thickness of different sculls, and of different
parts of the same scull, and at the same time reflect on the ex-
treme awkwardness of all these instruments, will immediately see
how very little dependence is to be laid on such defences, and
how mischievous the use of them must very frequently have
proved. In short, an attentive consideration of what our remote
ancestors have delivered down to us on this subject may satisfy
us, that their observations on the appearances and symptoms of
the ills attending this kind of mischief, that is, fractures of th€
cranium, were in general extremely just and true, perhaps more
so than those of many moderns; that their curative intention, or
method of aiming at the relief or cure of such ills, was rational
and just; but that the instrumental part of their art was so defi-
cient, so awkward, and so unhandy, that thiey were thereby not
only in general prevented from accomplishing the good they in-
tended, but were not infrequently driven into almost unavoidable
mischief.
Reduction of the number of instruments to be used in an ope-
ration, and an extreme simplicity and plainness in those which
may be required, are a part of the merit of modern surgery.
The majority of the instruments, with which our ancestors per-
forated the cranium, were contrived to make way for the admis-
sion of other instruments; such as the scalper excisorius, the cy-
cliscos, the scalprum lenticulatum, &c. with which they removed
a portion of bone. Even the modioli, which were used by them,
" cilium circulus alius parvus. Sane expedit complures id genus ad manum
" habere, ob quamcunque cranii crassitudinem ; nam crassiori longior conve-
" nit terebra, tenuiori brevior," &c.
Pet. Paaw in Hippocbat.
" Si autera validum fuerit os, prius illud terebellis abaptistis vacatis per-
" foratur. Ejusmodi vero sunt quse paulo supra acumen cuspidis eminentias
" habent, impedientes ne ad cerebriusque membranam demergi possint.*'
Paul. Mgiitbt.
l\2 IN.>L'RIES OP THE HEAD
were so small in the diameter of the saw, as to take away a very
small piece at each application; which circumstance necessarily
lessened the benefit which might be expected from the use of it,
and rendered its repetition more frequently necessary than it need-
ed to have been, if it had been made larger.
Instead therefore of that strange variety and multiplicity of in-
struments, which I have already mentioned to have been used by
them, we now require only a trephine of such a side as to remove
a sufficient quantity of bone at once, and an elevator; or perhaps,
now and then a pair of forceps. These are all we ever can want;
and these may be so made, as to be manageable by the hand of
any man of common judgment, with great ease to himself, with
very little fatigue and no hazard to the patient. With these we
can make as large or as small an opening in the scull as we please;
either for the relief of the dura mater, for the discharge of blood or
matter, or for the elevation of depressed or extraction of loose
pieces of bone, and that without disturbing the patient greatly,
or incurring any risk of wounding the brain or its membranes.""
I have already said, that what are called the principal and di-
agnostic signs of a fractured scull are by no means to be depend-
ed on, as indicating such mischief to exist; it can therefore be
hardly necessary to observe, that what are called the uncertain
signs require our regard still less. These have been mentioned
by many writers, who have copied each other; such are, the hold'-
ing a silk or horse-hair tight between the grinding teeth and the
hand, and the making it vibrate by striking on it; the biting an
" It has been customary to make the handle of the ti'ephine of iron, and to
form the extremity of such handle in such manner, as to make it serve the
purpose of an elevator ; thus combining', as it were, two instruments in one.
This, I think, is a great fault ; such iron handle adds considerably to the
weight of the instrument, and that in a wrong part of it ; and thereby renders
it less manageable. The handle of this instrument should be made of light
wood, not too long, and of an octangular figure. "Whoever will try the same
instruments, thus differently made, will, I think, be immediately sensible of
the preference due to the lighter handle. It is almost impossible for the han-
dle of an instrument, whose point or extremity is to be worked with, to be too
light. It is no uncommon thing to see couching needles, and instruments of
like kind, laden with heavy bone handles ; the Inconvenience of ^hich is too
obvious to mention.
t^ fi'on/-Fa<ff JJ2 VchI
FROM EXTERNAL VIOLENCE. 113
hard body, and attending to the pain produced by such action;
with several other of like sort; which, not to mention that they
imply the patient to be sensible and intelligent, arc so truly equi-
vocal as to deserve no notice."
All considerations, also, which are drawn from the manner in
which the violence was given or received, from the weight or
kind of weapon or body inflicting it, from the force of the blow,
the heightof the fall, &c. are all equally fallacious; for every body
knows, that very terrible symptoms and consequences are some=
times produced by accidents seemingly slight; and, on the con-
trary, that people escape unhurt, from what might reasonably
have been expected to have proved prejudicial to them. In short,
nothing but the sight and touch are to be at all depended upon.
If the integuments be not wounded, or if the wound made in
them be so small as not to admit a proper examination of the bone,
and the circumstances of the case be such as render such inquiry
necessary, a portion of the scalp should be removed. The man-
ner of doing this has formerly been the occasion of much differ-
ence of opinion; but there can be no doubt about the greater pro-
priety of removing a piece of the scalp for this purpose, by an in-
cision in a circular form, it being that form which must afford the
clearest view. If there be no wound, the point stricken should be
made the centre of the incision; if there be a wound, such wound
should be made the centre of the piece to be removed; and such
piece should always be of size sufficient to render the application
of the trephine easy." P
" " Item percutiatur caput cum levl bacculo sicco, de salice aut de pincj
" et pone aurem tuam apud caput ; et si sanum est, tunc audies soniiin sanum ;
" sifractum aut scissum, audies sonum mutum." LANruAsc.
" It may perliaps be remarked, that, through the whole of this'treatise, when-
ever I have occasion to speak of the operation of perforating the sculi, I men-
tion the trephine only, and take no notice of tiie trepan, the instrument used
by most of our immediate fathers, and stili in use through ahuost all France ;
my reason is, that the latter is an unmanageable one, and liable to most of the
hazard .and inconvenience attending the terebrse and terebellK.
P In a former part of this work, Mr. Po" has strongly expressed his dis^
approbation of removing any part of the scalp unnecessarilv On the same
principle, if any doubt exists of finding such mischief underneath the scalp
VOL. I. ' P
114 INJURIES OF THE HEAD
If the scalp be wounded, and the wound be large enough to
render the fracture visible, the course of that must be the opera-
tor's direction in making his incision; and if the skin be much
torn and bruised, or spoiled, it will generally be found adviseable
to take away all that is spoiled at once; as the removal of it will
add very little to the patient's pain, or the length of the cure; and
the leaving it in this state may be attended with great future in-
convenience.
Scalping (as it is called) should always be executed with a
knife, and that knife should be so held as to cut through the skin
and pericranium in a perpendicular manner, down to the bone at
once, that the size of the bare bone may be fully equal to that of
the wound in the scalp.
It is hardly necessary to insert a caution against pressing hard
with the scalping knife, in the case of large fractures, attended ei-
ther with great separation of the broken edges, or with loose pieces,
the danger is so obvious. And it is also as obvious, that there can
be but one method of avoiding such hazard; viz. by removing the
scalp from, or rather making the incision in apart beyond the frac-
ture, and where the bone is firm and stable. By these means,
not only the risk of hurting the membranes and brain will be
avoided, but the whole mischief will be more fairly and clearly
brought into view; a thing which sooner or later must be done, and
is always best done at first. No part of the scalp should be wan-
tonly or unnecessarily cut away: but it should always be remem-
bered, that this operation is, and should be performed, with in-
tention to bring, if possible, the whole fracture into sight; and
that whatever falls short of fulfilling such intention (if practicable)
is wrong, not only, as it does not immediately answer the purpose
for which it is intended, but it generally puts the patient under a
necessity of undergoing the same pain and trouble a second
time.
When the cranium is laid bare, it may not be improper to re-
as will make removal of bone necessary, I should recommend to make a cru-
cial incision, rather than at once to take away any part of the scalji. By a
crucial incision, a satisfactory examination may be made ; and if it be found
unnecessary to proceed further, the scalp may be laid down again, and pre-
served : if found necessary, it may be easily removed. E.
FROM EXTERNAL VIOLENCE. 115
mark, that writers in general have cautioned us to beware of
mistaking either a suture, or the impression of a vessel on the
surface of the bone, for a fracture: I say tha't they have in general
cautioned us not to mistake one of these for the other, but have
not informed us of the mark by which we may be enabled to
make the necessary distinction, although such mark is almost
constant and invariable. From the track of a fracture, or fissure,
the pericranium is always found loose and detached; whereas to
the arterial sulcus, and to the uninjured suture, it is ahvays
adherent; besides which, the edges of a fracture will always be
found rough to the probe or finger, and the sulcus always smooth;
not to add, that the disposition of the sutures is pretty certain,
and their appearance in general not extremely like to that of a
fracture.
When the scalp is much bruised, or wounded, such wound or
bruise points out the place from whence the piece should be re-
moved, in order to examine the bone; and, even although no frac-
ture should be found, is an authority and vindication of such
operation, especially if the general symptoms were at all urgent;
such symptoms implying mischief somewhere, and such external
mark rendering it clear, where the external violence causing such
mischief was inflicted. But all the ancient, and many of the
modern writers, speak of a particular kind of fracture, in which
the scalp covering it is perfectly fair and uninjured, and this they
call a contra-fissure. By the general account it is pretty clear,
that the majority of those who have spoken of this kind of frac-
ture have supposed that the breach made in the bone was most
frequently in the part of the cranium diametrically opposite to
that which received the blow; this the term contra-fissure implies,
and this they most certainly do in general mean should be under-
stood by it, as appears by their directing us to examine and to
remove the opposite part of the scalp, if no mischief be found
under the part stricken, and the patient labours under what are
called the symptoms of a fractured scull.
If the symptoms of a fractured cranium were certain, and to be
depended upon, this accidental circumstance, of a breach in the
bone having been now and then found in a distant, or ev'^en in the
opposite part, might be an inducement to look for such mischief
116 INJURIES OF THE HEAD
there, ulien it is not found uncicr the part stricken. A fracture,
we might then say, there is somewhere; and it having in some
instances been found in t-he opposite part of the head, it might be
i'ight to look for it there. But as what generally pass for, and are
called the symptoms of a fracture;! scull, are by no means to be
depended upon, as indicating such complaint to exist any where,
as they are producible by concussion, by extravasation, by contu-
sion, &c. and are frequently found ivhere the scull is entire and
unhurt, they cannot be deemed a sufficient authority for removing
the scalp where no apparent mark of violence is left. The smallest
degree of wound or bruise will, in cases where the symptoms are
urgent, vindicate the removal of scalp from such part; but where
there is no local indication where to operate, I cannot see any
vindicable reason for operating at all.''
The chirurgical intention in perforating the scull, in the case of
simple undepressed fractures, is, as I have already observed, either
to give immediate discharge to a fluid supposed to be extravasated
between the cranium and membranes of the brain; or to obviate
and prevent such ills, as may most probably be expected to arise
from the conajsion causing the fracture; or to let out matter already
formed iu consequence of the inflammation following such con-,
tusion.
In each of these it is most probable, that the mischief, be it
w'hich it may, either is or will be seated principally under the
track of the fracture; and therefore, whenever the trephine is
applied for either or any of these purposes, it ought always to be
set on in such manner as that the fracture should, if possible,
1 Morgagnij in his book lieCausis et Sedibiis, lias veiy justly observed,
" That if by contra-fissiire v/as meant a breach in that part of the cranium
" which is diametrically opposite to the part wounded or bruised, (as some
" have amrmed,) there could be none of that dinicuUy which they all allow
" of finding-, or that frequent disappointment in not finding it at all, since an
" inquiry into such opposite {)art must always have led to the discovery. So
" that, instead of the leim opposite, that of nnothcT p-Art of the cranium ought
" to have been used." And then t!ie whole of this, wljich has puzzled so
many, will amount'to no more than wliat every practitioner rnu.st kijow, wiiich
is, that we frequently find, in cases of great violence, that the scull has been
-broken in a i)lace very distant from that whicli received the blow, and which
we are not led to the knowledge of by any apparent external mark.
FROM EXTERNAL VIOLENCE. 117
traverse the circle described by ihe saw, or, at least, so that tlie
instrument might always comprehend the fracture within it.
I am aware that the direction given by most of the old writers
on this subject is very different from what I have mentioned; but
the instruments with which they operated were so different from
ours, and the advantages arising from the comprehension of the
fracture within the trephine are so great, and so manifest, that
I must take the liberty of inculcating a constant attention to it, as
to a circumstance from which great advantages are derivable.
The saw or crown of the trephine should never be too small,
especially if the patient be full grown; a circumstance which
I thought it right to mention, because the instrument-makers are
very apt to make them so,"^
The number of perforations which it may be necessary to make,
can only be determined by the nature of each individual case.
If the operation be performed on account of such symptoms as
seem to indicate a bloody extravasation, and so free a discharge
is produced by one opening, as alleviates or removes the symp-
toms, that one may be all that may be necessary; but if the first
perforation only discovers the disease, and is not followed by such
discharge as relieves or removes the symptoms, the operation
ought to be repeated again and again.
If there be no symptoms of extravasation, and the instrument
has been applied in a preventative sense merely, the length of the
fracture must determine the number; one or two only may be
made at first; and it may be right to wait for farther direction
from future circumstances. The circumstances which may ren-
der a repetition of the operation necessary are, accession or in-
crease of fever; large discharge of matter, or lodgement of the
,5ame fluid; inflammatory tension of that part of the dura mater
"f The best; practiliorcrs have, at times, found themselves ;iecesr,it:itcd to
apply the instrument repeatedly in the same case, in order to remove a con-
siderable quantity of bone; and among the writers on this subject, are frequent
relations of sucli facts. The practice is undoubtedly just and rii^ht; but I
cannot help thinl^.ing, from what I have seen of the perforating- instruments
of many of our predecessors, tliat a part of tlieir trouble, and of the fatigue of
their patients in such cases, might have been much lessened, hud the circle
of liieir saw been larger, Tlu' aclvantifgr; rf a lai-jv" ^:;:"(-'o is great ; the incon-
vcr,Icni:e in'iagir/un-.
118 INJURIES OF THE HEAD
which has ah'eady been denuded, &c. Directions to be given by
a writer can, on this subject, be only and truly general; all the
rest nnist be left to the judgment of the surgeon, which judgment
must be formed from the peculiar nature of each individual case.
When the operation has not been performed as a preventative,
but to give discharge to that matter which a symptomatic fever in-
dicates to have been formed, the quantity of such fluid, the ex-
tent of the secession of the dura mater, and the state of that mem-
brane, must determine the conduct of the operator. The only
chance of relief is, from laying bare a large portion of it, that the
discharge may be as free, and the confinement as little as possi-
ble; nothing but this can do good; the space of time in which it
may prove beneficial is very short, that once elapsed is absolutely
irrecoverable; and the necessary operation for obtaining such end
may full as well be totally neglected, as done by halves, or too
late.
The extent of the injured and separated dura mater, and con-
sequently of the vacuity for the formation and lodgement of mat-
ter, is a thing of so much consequence, that it is to be wished we
were able to discover it with more precision and clearness than
we seem to be able to do. It is the greatest circumstance of ha-
zard to the patient, and of direction to the surgeon. It is that
which, if undiscovered or neglected, must destroy the former, and
that, which when discoverable, and attended to by the latter, is
not only his information, but his vindication.
The concealment of the dura mater within the cranium is one
great cause of this great obscurity. This necessarily prevents us
from knowing the true state of that membrane, as much and as
certainly as it is to be wished we could; but still I cannot help
thinking, that there are some circumstances and appearances, as
well before perforation as after, which, if carefully and duly at-
tended to, may throw some light on this obscure part of surgery.
For example; if, upon dividing the scalp, the pei'lcranium is found
to be altered, and perfectly separated from the scull, to which it
ought naturally to adhere; or if, some few days after scalping, (as
it is called,) the edges of such wound spontaneously quit their
adhesion to the bone all round, io some distance, and instead of
being firm, florid, and healthy, become loose, tawny, and flabby;
PROM EXTERNAL VIOLENCE. 119
or if the scull, upon being denuded, is plainly of a colour different
from that of a healthy sound bone, with a healthy sound mem-
brane under it; or if such bone, after having been either accident-
ally or designedly laid bare, undergoes such morbid change of
aspect, and the patient is at the same time restless and feverish,
with tensive pain in the head, and irregularly returning fits of
heat and chilliness; I think that we may most reasonably presume,
that the dura mater in such patient is inflamed; and that the seat of
such inflammation is under such bare and altered part of the scull.
This presumption, as I have just observed, may take place be-
fore perforation; but, if added to these circumstances, which ap-
pear before the operation, vvc find upon perforating that the
membrane is inflamed, detached, altered from its natural texture
and brightness, or smeared over with matter, the case is then
clear, as to its nature; and it is as clear, that nothing but the re-
moval of a considerable portion of the scull can either give room
for the inflammatory tension of the membrane, or make way for
the discharge of matter generated on its surface; the two circum-
stances on which the well-being of the patient depends, the two
intentions which must be fulfilled, and which nothing but free
perforation can enable us to fulfil. Whatever degree of hazard
may be supposed to be incurred, by having exposed the dura ma-
ter to the air, cannot be increased by the mere comparative size
of the opening; and if we may be allowed to expose our patients
to any risk at all, it can only be upon a supposition that a greater
degree of good may be deducible from it.
It sometimes happens, that one of the bones of the scull is
cracked, and the dura mater underneath such crack is so injured
as to become inflamed, and in process of time to suppurate; but
there being no early or immediate symptom of such mischief, and
the scalp being neither wounded nor bruised in such manner or
degree as to authorise the removal of the scalp, the true nature of
the case is not known, nor the impending mischief attended to,
until the symptoms of inflammation begin to appear. In tliis si-
tuation, after an uncertain number of da^s, (sometimes more,
sometimes less,) the. patient finds himself out of order, is restless,
does not get natural or quiet sleep, is flushed and chilly by turns,
feels pain of the dull tensive kind ail over his head, but particu-
120 INJURIES OF THE HEAD
larly In the part where the blow was inflicted. Soon after he
has got into this state, the part so pained becomes in some degree
tumid, the febrile symptoms advancing notwithstanding every in-
ternal assistance. If in these circumstances the tumid part of the
scalp be divided, and the cranium be found bare, (the pericra-
nium having spontaneously quitted its adhesion,) whether it be
broken or not, mischief is certainly forming'' underneath it, and
the one remedy is perforation.
It also sometimes happens that a fine capillary fissure runs or is
continued under an undivided part of the scalp, from the extremity
of a fracture to a distance greater or less; or, in other words, the
fracture in its track, from being open and apparent, becomes
capillary, and is either not seen or not attended to. If the dura
mater, under such fissure, does not become inflamed, it may possi-
bly never give any trouble; but if it does become inflamed, .and
suppurate, the scalp covering such fissure will, at +he end of some
days, swell, and become tender to the touch; the pericranium
will, by separating from the bone, form a sinus along the track of
the fissure, a discharge of gleet will be made from it upon pres-
sure, and the division of it will display the breach in the bone.
Notwithstanding the fracture from which this fissure is con=
tinned be large and open, and the trephine may also have been
more than once used to such fracture, yet, when the appearances
are such as I have related, if the patient be not entirely free from
all general symptoms of inflammatory mischief, it may be de-
pended upon, ihdt the membrane under the fissure is diseased;
and if a convenient opening be not made upon the part aggrieved,
bad consequences will follow, notwithstanding all that may have
been done to the more visible and open part of the fracture; a very
strong and convincing pi'oof of the nature of a local inflammation
of the dura mater, as well as of the most proper method of treating
such disorder.
In cases of great violence offered to the head, whether the scull
' " Osslum vima oculta interdum non ante septimum diem, interdum nou
" ante decimum quartum, interdum serius se ostendit ; tum caro ab osse re-
" cedit; tumque os lividum apparet ; dolores item ichorum diffluentium es-
" citantur; atque hsc difficulter remediis ceduut.'^ HirrocEAX-
FROM EXTERNAL VIOLENCE. 121
be broken or not, it sometimes happens, more particularly in young
subjects, that we find a suture considerably disjoined; in which
circumstance I do not remember ever to have seen one single in-
stance of a recovery.*
I cannot take leave of this subject without reminding the young
practitioner, that although it be impossible for any one, in the
case of a highly inflamed or suppurating dura mater, to get well
without perforation of the scull, yet that operation must be
considered only as one absolutely necessary part of the pro-
cess toward obtaining a cure; and that phlebotomy, gentle eva-
cuations per anum, proper febrifuge remedies, and a strict low
diet and regimen, will be full as necessary after such operation as
before it. The removal of a piece of bone takes off some pressure
from the tense and inflamed membrane, frees it in some degree
from its confinement, and gives discharge to matter and gleet; but
it does no more; and every means which can serve to appease the
febrile heat, to lessen the velocity of the circulating fluids, to
render the skin perspirable, and the patient cool and easy, are fuH
as necessary after as before such operation.
CASE XVII.
SIMPLE FRACTURE.
A PRINCIPAL overseer of one of the great roads near to this
town was thrown down with great violence, while he was giving
directions to the labourers. He fell with his forehead against a
sharp stone, and lay senseless for a few minutes, but soon re-
covered himself, and walked home. The stone had made a con-
siderable wound, the lips of which were so torn and bruised, that
the surgeon who first saw him cut them away, and by that means
detected a fracture, or rather a fissure, of about an inch and a half
« " Repentina suturarum disjunctio, si causam attendas, sine aliqua cerebri
" concussione esse non potest : si effectum, non sine violenta crasse meningis,
" illuc magis adhserentis distractione, ac annectentium sibrillarum ac vascu-
"lorum laceratione." &c,
MoHPAGKi De Causis et Sed:
VOL. I. Q
INJURIES OP THE HEAD
or two inches in length, on the upper or middle part of the os tion-
tale. The man had neither sickness, giddiness, vomiting, fever,
nor any other bad symptom for several days; on which account
nothing was done to the fracture, which was dressed with dry lint
only. He was twice let blood, and kept to a low cool regimen.
At the end of seven days, he found himself so well, that he was
desirous of going out; but that not being permitted, he stayed at
home, and took great care of himself. On the eleventh day he
found himself out of order, said that his head ached, that his
stomach was not right, and ate no dinner. The following night
he got but little rest. On the thirteenth day, having passed very
unquietly the preceding night, he did not rise; and when his sur-
geon came to dress him, finding him feverish, he let him blood, and
gave him a lenient cathartic. In the space of two days more all
his symptoms were exasperated; his head-ach was great and con-
stant, his fever high, he got no sleep at all, the edges of the wound-
ed scalp became foul, loose, and spongy, and his forehead and
visage were attacked with an inflammatory swelling of the erysi-
pelatous kind. On the sixteenth day he had a severe rigor, and
was somewhat delirious, and his eyes became so tumefied that he
could not open them. In this state I found him. Being informed
of what I have here related, and having examined the bare
cranium, I could not hesitate to say, that I apprehended his com-
plaint proceeded from the formation and confinement of matter
■within the scull; and that the little chance the man had must be
from immediate perforation in the track of the fissure.
The operation was performed, and the dura mater found covered
with matter. He was dressed lightly, and lost twelve ounces of
blood.
The next day I was informed that he was very rational, but his
fever unremitting, and that he got no sleep. On the nineteenth
day I saw him again, along with the late Mr. Bethune; the dis-
charge from within the scull was large, and the bare bone and
wounded scalp looked very ill; all his other symptoms much the
same.
On the twenty-first I was sent for again. He was now deliri-
ous in a high degree, paralytic in one arm and leg, and frequently
convulsed in the other; the discharge was large and remarkably
PROM EXTERNAL VIOLENCE. 123
offensive, his tongue black, the skin of his body burning hot and
diy, that of his extremities cold and moist, and I suppose I need
not tell the reader what happened that night.
CASE xviir.
A YOUNG man playing at cudgels in Moorfields received a stroke
on his forehead; it did not seem either to himself or the specta-
tors to have been a severe one; but as it produced blood, it was
deemed by the laws of the game a broken head, and he was
obliged to yield to his antagonist.
As it gave him no trouble, he took no notice of it; was for
several nights afterwards engaged in the same diversion, and
followed his daily labour. On the ninth day from that on which
he received the blow, he thought that his forehead was somewhat
swollen, and felt tender to the touch; on the eleventh it was more
tumefied and more painful, and on the twelfth he found himself
so much out of order, that he applied to be received into St.
Bartholomew's hospital.
An incision was made into the tumor; a thin brown ichor was
discharged; and a bare bone being discovered, a circular piece of
the scalp was removed, which discovered a fracture. The tre-
phine was applied twice along the track of the fracture, by which
means it was almost totally removed. The dura mater was found
discoloured, and beginning to have matter on its surface. The
patient was let blood, and ordered to take the sal absinth, mix-
ture, with a few grains of rhubarb in it every six hours. The
succeeding night was passed ill; the patient complained much of
pain, and got little or no sleep. On the fourteenth his fever was
high, his skin hot, and his pulse full and hard; fourteen ounces
more of blood were taken from one of the jugulars; and as he
still continued costive, a lenitive purge was given a few hours
afterwards. On the seventeenth every thing bore a bad aspect,
both as to his wound and his general state; he got no rest, his
fever was high, and the wound very ill conditioned. His head
was again carefully examined, in order if possible to discover
some other injured part. No such injury was found; and it being
1S4 INJURIES OP THE HEAD
impossible that he should remain in his present state, evacuation
seemed to be his only chance, and therefore fourteen ounces more
of blood were drawn from one of the temporal arteries, by which
he fainted, and afterwards seemed to be somewhat easier.
For three days from this time he seemed to be considerably
better; but on the twenty-first he was again in as much pain as
ever, and the sore again began to put on a bad aspfect.
The benefit which he had once already received from phleboto-
my had been manifest; and as his pulse was well able to bear it
again, the temporal arteries were again opened, and he was bled
till his pulse failed so much and so suddenly, that I was not a
little alarmed. By proper care he was brought to himself, and I
had no other trouble during his cure than what proceeded from
his extreme weakness, which the bark soon removed.
Although this man may very justly be said to have been saved
by the frequent repetition of phlebotomy, yet as matter was
beginning to be formed on the surface of the dura mater, and as
such matter could have no outlet whereby to escape, it is very
clear, that, unless the cranium had been perforated, he must have
perished.
CASE XIX.
The driver of a post-chaise was thrown fi'om his horse near
Ware in Hertfordshire, and struck his head against what they
call a stepping stone in a wash-way. He was stunned by the
blow, and carried into a public, house; but in half an hour's time
found himself so well as to be able to carry the chaise to the place
he was going to, which was just by. The next day finding him-
self perfectly well, he went to work again, and continued to do
so for six days. On the seventh, he found himself sick, vomited
twice, and had a kind of fainting fit followed by a great pain in
his head, and some degree of fever. From the hardship and the
irregular manner of these people's living, his complaints were
supposed to be owing to cold, and to intemperance, and he was
treated accordingly: but on the ninth day, a tumor appearing on
that part of his head which had received the blow, a surgeon ex-
PROM EXTERNAL VIOLENCE. 125
amined it, and, upon opening the tumefied part, found a fissure
running diagonally across the whole parietal bone. The next
day he was brought to St. Bartholomew's hospital. His skin
was hot, his pulse hard and quick, and he complained that his
head felt as if it was squeezed between two trenchers. The
whole fissure being brought into view, the trephine was applied
three times along the track of it; from each perforation a quan-
tity of matter was discharged, and under each the dura mater
was much altered. All possible care was taken of him, but to
no purpose: every day produced an exasperation of his symp-
toms. On the fourteenth he became paralytic on one side, and
on the sixteenth sunk into a state of perfect insensibility, and
toward evening died. The whole internal surface of the left
parietal and temporal bones was detached from the dura mater,
and covered a large quantity of matter.
CASE XX.
A bricklayer's labourer was knocked down by the fall of a
large heavy pantile, which made a large wound in the scalp, and
broke the scull. The fracture began in the left parietal bone,
and, traversing the coronal suture, ran about an inch in the os
frontale.
He was soon brought to the hospital, where the scalp was im-
mediately removed, so as to make way for the trephine; which
instrument was applied on each side of the suture, in such man-
ner as to comprehend the fracture in each application of it.
The dura mater was found to be uninjured; there was neither
extravasation, nor any other mark of mischief. The patient was
freely and repeatedly let blood, kept to a proper regimen, and pre-
scribed for by the physician. In two months he was discharged
perfectly well, and had not during his cure one single bad symp-
tom.
It may very reasonably be remarked, that this was one of those
cases which might have done well without the operation, which I
am much inclined to believe: but does not this case, as well as
126 INJURIES OF THE HEAD^
many others of like sort, prove also, that the laying bare the un-
injured dura mater is not a matter of such hazard, as some have
supposed it to be?
CASE XXI.
A GIRL about nine years old fell from the top of a pretty high
hay rick at Islington, and pitched with her head on the ground,
which was hard and dry. She was carried home bleeding freely
from a wound on one side of the upper part of the head, and a
surgeon in the neighbourhood examining her, found that her scull
was broken; upon which she was brought to the hospital. The
fracture was detected; it began in one parietal bone, and, passing
the suture, ended in the other, making a course of about three
inches in all. It was open, and blood discharged through it.
The trephine was applied to it on each bone; the dura mater
was not hurt. She had neither sickness, stupor, pain, nor fever,
and got well without any trouble; not even an exfoliation from the
bare cranium.
The same remarks as were applicable to the foregoing case
are, perhaps, equally so to this.
CASE XXII.
A farrier's servant received a blow from the foot of a horse
which he was shoeing. The blow knocked him down, and be-
reaved him of sense. He lived near Smithfield, and was brought
to the hospital senseless.
I saw him in less than half an hour, and found him to all ap-
pearance well, his senses perfectly recovered, and no remains of
the injury visible, save a small bruise on his forehead. A discu-
tient cerate was applied to the bruise, he was let blood, a purge
was ordered for the next day, and he was advised to keep very
quiet.
On the third day he was perfectly well, had no general com-
FROM EXTERNAL VIOLENCE. 127
plaint, and the bruise on his forehead was what is commonly called
black and blue-
He continued well until the evening of the seventh day, in
which he complained of being faint, chilly, and uneasy in his
head, particularly his forehead. The following night he was rest-
less, and in the morning was sick and giddy, and had no appetite.
His pulse was very little risen; however, twelve ounces of blood
were taken from his arm, and he was ordered to take the sal ab-
sinth, mixture sextis horis, and keep in bed. The ninth and tenth
days were passed in much the same manner; but on the eleventh
his fever rose high, and the part of his forehead which had re-
ceived the blow became swollen and tender. On the thirteenth
the tumefied part palpably contained a fluid, and was therefore
opened. A fracture about two inches in length was discovered,
running from just above the frontal sinus upward. The trephine
wa? applied in the most depending part, and matter found between
the membrane and bone. The day after this operation, finding
his pulse to be full and hard, I bled him so freely that he swooned,
and was some minutes before he recovered. That night he passed
much easier; and although the discharge of matter was consider-
able for some time, yet, by proper care and due management, both
physical and chirurgical, he got well.
I will not assert it to be a general fact, but as far as my own
experience and observation go, I think that I have seen more pa-
tients get well, whose injuries have been in or under the frontal
bone, than any other bones of the cranium. If this should be
found to be generally true, may not the reason be worth inquiring
into.'*
* That this is true, has been proved by many instances. The cause is in
great measure assigned, if we recollect that the cerebrum may be hurt with
less danger than the cerebellum ; and that the greater the distance of a wound
from the cerebellum, the less danger there is of that part of tlie contents of
the cranium being injured. It has been frequently demonstrated, that great
part of the cerebrum may be taken away without destroying the animal, or
even depriving it of its faculties ; whereas the cerebellum will scarcely admit,
the smallest injury, without being followed by mortal symptom?. K.
INJURIES OF THE HfeAD
CASE XXIII.
A LAD about seveoteen, the son of a plasterer, was at work with
his father at the mansion-house, and fell from a scaffold a consi-
derable height. He lay senseless for some minutes, but in a little
time was so much recovered as to walk. On the left side of his
head was a small bruise, which gave him little or no pain. He
had no symptoms which indicated that he had sustained any mis-
chief; and after having staid at home a day or two at the per-
suasion of his mother, he returned to his business. On the ninth
day from that of his fall, he was seized with a violent shooting paio
in his head, was sick, and had a kind of convulsive fit.
As it was not supposed that his fall had any share in that attack,
no notice was taken of it; a few ounces of blood were drawn from
his arm, and the apothecary who had the care of him gave him
some of those medicines that are called nervous.
His head-ach, fever, and watching, continued without remis-
sion for several days, and at the end of three weeks he died, para-
lytic on one side, and convulsed on the other.
A small swelling having appeared on his head three or four days
before his death, his father desired me to come and look at it, aftei*
that event had happened.
The pericranium was separated from the left parietal bone quite
across, by means of a fracture which traversed the length of the
whole bone. A quantity of matter was lodged between the inner
surface of the said bone and the outer one of the dura mater, and
a smaller collection of matter was also found between the mem-
brane and the pia mater.
CASE XXIV.
A YOUNG man about twenty-two was brought into St. Bar-
tholomew's hospital, considerably hurt by a fall from a high
scaffold.
The radius of his right arm was broken about its middle; the
T^ROM EXTERNAL VIOLENCE. 121)
tibia and fibula of his left leg were both broken, and one or two of
his ribs.
By proper care, in about five weeks, he was so well as to be
permitted to get out of bed. The first day of his rising he com-
plained of being sick and giddy, which was imputed to weakness
and confinement, and therefore disregarded. For three or four
days after this period he complained of constant pain in his head,
got no sleep, and was constantly feverish. As he had never made
any complaint of his head, nor had apparently sustained any in-
jury on that part, Mr. Nourse (whose patient he was) could not
suspect any, and therefore contented himself with the common
antiphlogistic regimen. At the end of the sixth week, he com-
plained that his head was painful to the touch; and, the day after
he had made this complaint, he had a severe rigor, which lasted
half an hour. On the twenty-ninth day, a swelling, palpably
containing a fluid, appeared on one side of his head. Mr. Nourse
opened it, and found a fracture of the parietal bone three inches
long at least, through which matter issued freely. The trephine
was applied, a large quantity of matter was discharged, and the
dura mater was found sloughy; under which sloughy part was
another collection of matter between the membranes, and under
this latter abscess the brain was considerably discoloured. He
died on the fiftieth day from that of his fall.
CASE XXV.
A Bot, belonging to a horse-dealer in Smithfield, was thrown
from a horse, with great violence, against one of the sheep-pens.
He had a large wound and a fracture, which began about the
middle of the frontal bone, and, passing the coronal suture, ended
in the right parietal.
A trephine was set on the fracture in the frontal bone, and a
small quantity of grumous blood discharged from between the
cranium and dura mater. All that day and night he continued
senseless; but the next day, by means of a second plentiful bleed-
ing, he recovered his senses. To render every thing (as I hoped)
VOL. r. Br
1^0 INJURIES OB^ THE HEAD
secure, a small trephine was applied on the other side of the su-
ture, which seemed to comprehend all the breach made in the pa-
rietal bone.
For nine days from this time every thing looked well, and the
boy was free from complaint; but, on the twelfth from the acci-
dent, he complained of being much out of order; and the next day
the sore looked ill, and a thin gleet was discharged from the dura
mater through the lint, which now stuck fast to it, instead of
coming off easily as usual, and covered with good matter.
For three days from this time, both the boy and sore remained
in much the same state. On the seventeenth, in dressing him, I
observed a spongy kind of papilla on one part of the sore, which
was very tender to the touch, and from which was discharged,
upon pressure, a thin sanious kind of fluid: by means of a probe
passed through this papilla, I discovered a sinus with bare bone
its whole length: the division of this detected a capillary fissure, of
at least two inches in length. A trephine was set on it, and the
dura mater was found discoloured, and with matter on its surface.
By means of free evacuation at first, and as free use of the bark
afterwards, this patient got well.
CASE XXVI.
Two female inhabitants of St. Giles's got drunk together, and
quarrelled; one of them threw a stool at the other, and knocked
her down. The edge of the stool cut through the scalp, and
broke the left parietal bone. The fracture ran from the middle
of the bone as far as the sagittal suture. The girl was dressed
that night by somebody in her neighbourhood, and was brought
the next morning to the hospital. As she had no bad symptom of
any kind, the operation was deferred, and she went on very well
for a week; at the end of which time she began to complain in
such manner, and her sore shewed such an aspect, that I thought
Uiere must be mischief under the cranium. A trephine was set
on the fracture; the dura mater was found sloughy and purulent.
She was bled again freely, and took proper medicines. On the
fifteenth day she had tV shivering, and after it a very brifikXever.
PROM EXTERNAL VIOLENCE, 131
On the seventeenth she was worse in every respect. On the
eighteenth a tumor appeared on the other side of the head. This
was opened, and a fissure discovered in the right os parietale. A
trephine was set on this fissure, and a discharge given to a large
quantity of matter. Every thing that could be done for her was
done; but on the twenty -third day she died.
The dura mater was separated from both the parietal bones,
and matter found in large quantity under each.
It was for many years a generally received opinion, that one
use of the sutures of the cranium was, to prevent the passage of
a fracture from one of the bones to another.
This purpose they may undoubtedly have often accidentally
served; but that they are generally incapable of so doing, mani-
fold experience evinces. Fractures are often seen to pass regu-
larly through a suture, from one bone to the adjoining, without
any discontinuation or impediment. This is a fact which ought, by
writers, and lecturers, to be constantly inculcated, as an inattention
to it may be of very bad consequence to individuals; for the
practitioner who supposes that a suture will certainly, or not
unfrequently, set bounds to a fracture, will, when he has traced
such a kind of breach in one bone as far as the suture into which
it may happen to run, not think it at all necessary to go farther
and examine the adjoining bone.
A suspicion of the stricter adhesion of the dum mater to the
scull at the places of these sutures than every where else, the
situation of what are called sinuses immediately under the sutures,
and a fear that either high and dangerous inflammation must
follow the violent detachment of a part of them, or that an unre-
strainable and fatal hasmorrhage must ensue from a breach of those
vessels which pass from the sinuses through the sutures, have deter-
jed most of our ancestors from meddlhig with them, and induced
them to deliver down to us frequent prohibitions against the appIi-»
cation of perforating instruments upon them. Neither of these
apprehensions is founded in fact, or in strict truth. The sepa-
ration of the scull from the longitudinal sinus is not attended neces-
sarily with any kind or degree of inflammation peculiar to itself^
or more than any other part of the dura mater; nor is the lacera'
Hon or breach of the communicating vessels between this sinus
130^ INJURIES OP THE HEAD
and the suture which covers it, necessarily followed by any such
degree of haemorrhage as to prove hazardous or alarming; as I
have more than once experienced.
A perforating instrument most certainly ought not wantonly or
unnecessarily to be set on this part; and this for a reason not
drawn from any peculiar hazard attending such operation. The
larger size, and greater number of vessels here than in other parts
of the bone, will certainly ceuse such a degree of bleeding, or
haemorrhage, as, though easily restrainable when the piece of bone
is removed, may yet, in the act of perforation, considerably em-
barrass and perplex a young operator: it will therefore behove
him, in general, to avoid comprehending the sulure within his
saw; but still it is right that he should know, that, when parti-
cular circumstances render it absolutely necessary, such thing
may be done very consistently with his patient's safety. Not
only a part of the sagittal suture, covering the longitudinal sinus,
may be removed with a trephine, if necessary, and no hazard be
incurred from the breach of the attaching vessels; but a wound
of the sinus itself is by no means necessarily attended with an
unrestrainable or fatal haemorrhage.
The very writers themselves, who are so apprehensive of a
wound of this part, forget the relations they every now and then
give us of fragments of broken bone safely extracted from it.
A mistake concerning the nature of the sinuses was (I suppose)
the foundation of these apprehensions. The idea which most of our
ancestors had of the motion of the dura mater induced them to
believe, that, as the sinuses were composed of this membrane, a
wound made in them, like a wound in an arterial tube, could
hardly re-unite. It is now universally known that they are merely
venal, and that there is no such impediment to the immediate
coalescence of a wound in them, when it may happen to be acci-
dentally inflicted.
CASE XXVII.
A BOY, about eight years old, the son of a Jew merchant in
the city, received a blow on his head with a stick from his tutor.
FROM EXTERNAL VIOLENCE. 133
The stroke made him giddy for a few minutes; but as no blood
was shed, and the pain soon ceased, he concealed it till it was
discovered by his barber that his head was swollen in that part.
In the middle of the top of his head was a tumor, about the size
of a common walnut: it was indolent, had a dull kind of pulsa-
tion, and palpably contained a fluid.
Mr. Serjeant Amyand and Mr. Shipton were joined with me.
In their presence I divided the tumor with a knife, and let out a
quantity of fluid venal blood. When as much had been dis-
charged as the tumor might be supposed to have contained, we
were surprised to find the blood still continue to flow, plainly not
from the wounded scalp, but from the bottom of the cavity.
Upon examination, it was found that the sagittal suture was
broken, that a portion of the fracture was forced into the sinus, and
that the blood issued by the sides of this fragment.
Extraction of this fragment was attempted, but to no purpose.
By the direction of the consultants, I made a small perforation on
one side of the suture; but when that was done, the point of the
elevator could not be so introduced as to get the broken piece out.
The trephine was then applied on the other side of the suture, and
to the same effect, or rather no effect. The fragment was only
capable of being extracted as it had gone in. At last, after much
deliberation and conversation about the hazard of wounding a sinus,
(which was indeed already wounded by the broken bone,) it was
agreed to set a trephine on the suture, in such manner that the
whole surface should be comprehended within its circle. This
was done; but when the elevator was applied, the piece sawed
came out in fragments, and left the one portion which had pierced
the sinus still sticking in it. We were then necessitated to lay
hold of it, and extract it with a pair of forceps. A flux of blood
followed, but, by the application of a small dossil of dry lint, held
on for a few minutes, it ceased, and never recurred. The patient
is alive at the time of my writing this,
CASE XXVIII.
A GIRL about sixteen was knocked down by her mother with an
iron poker of considerable weight; the latter immediately ran
134 mJURlES OF TiiE HEAD
away, and the former was brought senseless to the hospital. She
had a large wound on the top of her head, with a considerable
fracture of the sagittal suture. The broken pieces were so large,
and so loose, as to be easily removeable without any perforation.
When they were taken away, the longitudinal sinus was left bare,
at least two inches in lengthj but no hjemorrhage followed the
removal of the fragments.
For three days she was bled twice a day, from one part or other
of her, and stools were procured in such manner as was possible,
but to no purpose; she still remained perfectly and absolutely
senseless. On the fifth day, finding her still in the same state,
and verily believing that nothing in art could at all serve her, I
made an opening widi a lancet into the longitudinal sinus, and
suffered the blood to run off, until her countenance, which was
much flushed, became pale, and her pulse, which till now had
been full and strong, though labouring, faltered considerably; in
short, till she shewed as much as a senseless person could the
marks of a deliquium from inanition. I then put a bit of lint on
the orifice, and ordered the nurse to keep her finger lightly on it
until I had visited the rest of the house. When I returned, the
part shewed no disposition to bleed again, nor did it ever after.
That afternoon she opened her eyes and moved her arms, and the
next morning was sensible enough to ask for drink. She retained
her senses for several days, but a fever coming on, she became
delirious and convulsed, and died so on the seventeenth day from
that of her admission into the hospital.
Upon examination, after death, a considerable abscess was
found on the surface of the brain, on one side of the falciform pro-
cess of the dura mater.
I should be very sorry to be so misunderstood, as to have it con-
ceived that I have related these cases with a view to encourage
the opening of a longitudinal sinus; that is far from my intention.
I only mean, by adducing these instances, to prove that our fears
of irremediable mischief from such wounds, whether accidentally
or artificially inflicted, are not well grounded; and that we may,
in some desperate cases, have recourse to such means as have been
supposed to be either impracticable or unwarrantable. A surgeon
PROM EXTERNAL VIOLENCE. 135
should ever be cautious; but ill-grounded apprehensions will ne-
cessarily prevent improvements, and hinder us in some cases froin
attempting what may prove beneficial to mankind. Had every
successor to Hippocrates been of his opinion, the operation of
lithotomy had never arrived at its present state of i>erfection, and
mankind had been suifered to languish under, and be destroyed by,
a most tedious as well as excruciating malady.
SECT. V.
FRACTURES OF THE CRANIUM WITH DEPRESSION..
. Simple fractures of the scull, or those in which the parts of the
broken bone are not depressed from their situation, differ from
what are called fissures, only in the distance of the edges of breach
from each other. When the separation is considerable it is called
a fracture, when it is very fine and small it is called a fissure.
The chirurgical intention and requisite treatment are the same in
each, viz. to procure a discharge for any fluid which may be ex-
travasated in present, and to guard against the formation or con-
finement of matter in future. But in fractures attended with de-
pression, the intentions are more. In these, the depressed parts to
be elevated, and such as are so separated as to be incapable of re-
union, or of being brought to lie properly and without pressing on
tlie brain, are to be totally removed.
These circumstances are peculiar to a depressed fracture; but-
although they are peculiar, they must not be considered as sole,
but as additional to all those which have been mentioned at large
under the head of simple fracture: commotion, extravasation, in-
flammation, suppuration, and every ill which can attend on or be
found in the latter, are to be met with in the former; and will
require the same method of treatment.
To free the brain from pressure, and to provide a free discharge
ibr blood or lymph at present, or for matter in future, by elevating
136 INJURIES OF THE HEAD
the depressed pieces, and by removing such as were loose, was as
well known to the ancients to be the proper curative intentions,
as they can be to us; but the means which tliey made use of in
order to accomplish these ends were somewhat different to what
are now used; and laboured under some inconveniences which
later practitioners have corrected. This difference it may be worth
while to inquire into.
Most of the attempts made by our ancestors, for the elevation
of depressed parts of the cranium, were made by the application
of instruments to the parts so depressed. This was a palpable
imperfcQtion, to say no more of it; but this was not all; for the
instruments which they made use of on these occasions were not
only to be fastened to the depressed part of the bone, but required
also some degree of force to be used in fastening them to such
part. The troclea tripes, the troclea bipes, and all the pieces of
machinery designed by Albucasis, Guido, Andreas a Cruce,
Fabritius ab Aquapendente, Pare, and Scultetus, as well as thoge
delineated by Hildanus and Peter Paaw, are proofs of this: they
all require a perforation to be made in the depressed piece, either
by or for the screw' with which it is to be elevated. Now, not to
mention that most of these instruments were so complex as to ren-
der them extremely awkward and unmanageable, it is obvious,
that, by the application of any of them to the depressed pieces,
(especially if they were loose,) all the ills arising from pressure
made on the parts underneath must be increased; and that in
many cases they could not be used at all. Celsus has indeed
directed the meningophylax to be used as an elevator; which
instrument differs but little from the elevator used at present,
either in form or manner of application; but then the opening
through which it is to be introduced is to be made either with the
terebra or the cyciiscos, the inconveniences of which have already
been remarked. In short, all the objections which the old per-
forating instruments were liable to in simple undepressed fractures
being of still greater force in fractures with depression, and the
application of any kind of instrument whatever to the outer sur-
face of a depressed or loose piece of scull being palpably wrong,
and liable to hazard, the present practitioners are certainly vin-
d.icable in having laid them all aside, and in having endeavoured
TROM EXTERNAL VIOLENCE. 137
to accomplish the same end by means which are less hazardous
and less operose. The trephine is (as I have before observed)
the only perforating instrument used by the best of the present
practitioners in England:** with this, an opening is made in the
sound undepressed part of the cranium, and through such opening
an instrument, called from its use an elevator, is introduced. This
perforation should either comprehend the border of the fracture,
where that is possible, or if that cannot be conveniently done, should
be made as near to it as possible, for reasons too obvious to need re-
cital. What number of perforations may be necessary can only
be determined by the particular circumstances of each individual
case: all the intentions which may arise from extravasation of
fluid, or probability of suppuration, as well as those from the de-
pression of bone, nlust be fulfilled, or the work will be left imper-
fect, and little chance of good will attend it.
When the whole disease seems to consist in the mere depres-
sion of the bone, and what symptoms attend seem to proceed from
that alone, the elevation of such portion may procure immediate
remission of such symptoms, and afford a reasonable prospect of
success. But as the injury is not always of so simple a nature, as
other parts are so frequently hurt and other mischief done by such
great violence, the remission, or disappearance of such symptoms
as arise merely from such pressure, cannot be a sufficient war-
rant, either for promising or for expecting success. The dura
mater under the depressed piece, or even in another part of the
head, may have been so hurt as to become inflamed, and to sup-
purate: the symptoms of which will not appear immediately, nor
in general until some time is past: but however late they may
come on, they will not therefore be the less certain or the
less hazardous. The early attack of those which are caused
by extravasated fluid or depressed bone, does by no means
» M. Savigny, in his work on Chirurgical Instruments, has exhibited a tre-
phine on a new and improved construction, which is divested of lateral teeth,
and made on the same principles as the amputating saw ; it certainly per-
forms its office with celerity and neatness, and with less exertion to the
operator than that before in use. The perforator having sufficiently fixed
the saw in the circle, is by a contrivance made to retire, which precludes the
necessity of removing it by means of a key. E.
VOL. I. S
138 INJURIES OP THE HEAD
preclude the later accession of such as arise from inflamma-
tion and putrefaction. The depressed piece of bone does most
certainly require our immediate help, but the assistance lent to
that, however proper and effectual, does not render it at all less
necessary to guard against such ill as may most reasonably be ex*
pected to proceed from violence sustained by the parts underneath.
A blow, which has been sufficient to break and depress a portion
of the scull, very frequently does such damage to the tender ves-
sels which communicate between that bone and the meninges, as
to be the cause of niuch more, as well as greater ill, than what is
deducible from the mere fracture; and consequently, although the
elevation of the bone is one very necessary part of a sui'geon's bu-
siness in these cases, yet it is very far from being all that he has
to do. All the ills which may be apprehended from every other
possible effect of such violences, are to be feared and guarded
against, and that full as much in the fracture with depression
as in that without.
This is a part of practice which ought to be very carefully at-
tended to. The generality of writers have contented themselves
with directing us to raise up the depressed parts, and thereby to
endeavour to remove such symptoms as are caused by the mere
pressure which the bone makes on the brain; but have either to-
tally neglected, or very slightly passed over, what is of full as
much consequence to the patient; I mean the injury which is most
frequently done to the membranes of the brain, and which, if ne-
glected, will certainly produce that fever, and those symptoms,
which so often baffle the whole power of medicine.
The combination of different ill effects, proceeding from the
same primary violence, and concurring in the same subject, to-
gether with the great difficulty of distinguishing them from each
other, is one of the principal causes of that perplexing uncertainty
attending wounds of the head. When one cause of bad symp-
toms has been removed, another, or even several others, may still
remain, each of which singly may be sufficient to destroy the pa-
tient; and therefore, although the means first made use of may
have been such as have been pointed out by the earliest and most
alarming symptoms, and extremely proper for the relief of such
complaint, had it been the only one the patient laboured under,
FROM EXTERNAL VIOLENCE, 139
yet in the case of a complication, by not being sufficient to an-
swer every requisite intention, they very often answer none, at
least not effectually; and producing only a temporary and partial
relief, prove a greater aggravation of our disappointment.
This every practitioner should know, and this the friends of
every patient should be made acquainted with, lest the former, be-
ing deceived by an appearance of amendment, be induced to pro-
mise what it will not be in his power to perform; and the latter,
having had their hopes exalted, should be the more severely hurt
by their disappointment.
If the fracture be but small, the depression little, and the force
with which it was produced not great, the elevator introduced
through the perforation may be sufficient to set it to rights; and if
there be no urgent symptoms, nor any mischief done to the inter-
nal parts, may be sufficient for all purposes. But if the force was
great, if the symptoms are immediate and pressing, if the fracture
runs in a form inclined to a circular one, or if the depressed piece
be cracked all round, the best and safest way is to remove the
whole, or greater part, of the portion so depressed or circam-
scribed.
To those who are unused to things' of this sort, so large an
opening as such method of acting must make will have a very
tremendous appearance; and they may be inclined to suspect
much hazard and inconvenience from laying bare so large a por-
tion of the dura mater; but let all such remember, that however
large the quantity of membrane may be which shall be thus de-
nuded by the operation, yet the same quantity at least, most pro-
bably a much larger, would, in all likelihood, become inflamed, and
generate matter on its surface; which matter, for want of a timely,
ready, and sufficient outlet, would do considerably more mischief
than the mere detection of the said membrane can do.
In cases where the broken pieces of a depressed fracture are
widely separated from each other, and some of them a good deal
loosened, the expediency and the propriety of removing such pieces
are acknowledged by every body; but few people attend to the
reason, or inquire why such practice is just and proper; if they did,
thev would also see that the free removal af bone was equally
140 INJURIES OP THE HEAD
proper in the case of great violence, as in that of loosened or
widely separated pieces. In the latter the broken parts are re-
moved, because their reunion with the rest of the cranium, and
the preservation of the attachment of the dura mater to the inner
surface of them, is thought impossible, or at least highly impro-
bable; and that therefore they must be in the way, arid hinder the
free discharge of matter from the suppurating membrane. And
is not the same inconvenience full as likely to attend the former?
Is it the violence done to the bone, and through it to the mem-
brane, which causes the inflammation and suppuration? Oris it
the loosened or separated state of the broken part? If it be the
former, (as it most undoubtedly must be,) the same precautions, the
same method of treatment must be equally necessary in the one as
in the other; the reasons, the intentions, are the same in each:
and if the conduct be not the, same the patient will suffer.
The peculiar circumstances of each individual case must fur-
nish direction to the practitioner for his particular conduct. Rules
to be laid down by a 'writer on such subject can be only general.
The parts which are depressed must be elevated; such as are
loose and cannot be brought to lie even, such as cannot be pre-
vented from pressing on the membrane, or such as wound and ir-
ritate it, must at all events be taken away; the free discharge of
blood or lymph in present, and of matter in future, must be pro-
vided for; and therefore every symptom and appearance must
carefully and early be attended to, lest the most proper opportu-
nity of giving assistance be not embraced.
The circumstances just mentioned are such as cannot be ne-
glected but at the risk of the patient; and therefore the prohibi-
tions which our forefathers have delivered down to us, with regard
to the parts of the scull on which they say we ought not at any
rate to apply our perforating instruments, must be received with
some limitation.
The places forbidden as improper are, the sutures, the lower
part of the os occipitale, the ossa temporum, and that part of the
OS frontale where the sinuses are situated.
That a trephine may without hazard be applied on a suture, I
have already said. , When it may with equal utility be set on any
other part, the sutures should undoubtedly be avoided, and that
FROM EXTERNAL VIOLENCE. 141
for a good reason, exclusive of any peculiar hazard: but that part
of a suture may (the case requiring it) be safely removed, is true
beyond all doubt. That many of the old practitioners were very
apprehensive of mischief from hence, is not to be wondered at by
any body who considers their idea of the nature of the subjacent
sinuses, and the strange unmanageable instruments with which
they operated. Not that there are wanting old writers who have
held the doctrine of operating on a suture, when necessary, very
defensible; among whom is J. Baptist. Cortesius.
Perforation of the temporal bones has been forbid, both on ac-
count of the artery and the muscle which are on its surface; unre-
strainable hasraorrhage having been dreaded from the one, and
fatal convulsion from the other: but, experience may convince us,
that neither of these apprehensions is strictly just. The tempo-
ral artery, when divided, is often capable of being restrained by
compression, and always by ligature; and that fatal convulsion,
which is vulgarly called the lock-jaw, though it produces one of
its most striking and most visible effects on these muscles, is not
necessarily produced by a wound of either of them, more than by
a wound of any other. In short, the upper part of the temporal
bones may be laid bare, if necessary, by an incision made through
the muscles covering them; and may also be perforated. Such
operation does not indeed often prove successful; but the failure
of success does not proceed from the nature of the parts operated
upon, but from a circumstance of much more consequence, and
generally w^ithout remedy; which is, that in these fractures the
breach is most commonly continued on to the basis of the scull,
and is also most frequently attended by a large extravasation
within or under the brain and cerebellum.^
When the depressed parts have been raised up, the loose ones
removed, extravasated fluid discharged, the brain freed from pres-
sure, and way made for the free exit of whatever may be formed.
or collected, the bare dura mater should be dressed as easily and
" Whoever will examine the clisposilion of the temporal m\isc]e will see,
that its iiponeiirosis covers a verj- considerable part of the inferior border of
the OS parietale ; and, consequently, that such part of tlie bone can never be
laid bai-e vvilliou'r a division or removal of a part of Ih:- said aponevirotic ex-
pansion.
142 INJURIES OF THE HEAD
lightly as possible. Our ancestors had a multiplicity of medica*
ments, which they used upon these occasions, and wero very pre-
cise in suiting them to the different states (as they called them)
of the sore and membrane. They were also very exact in making
and applying those pieces of linen or of silk, called sindons, which
they used to imbue with the said remedies, and dress the bare
dura mater with. I have taken no notice of either, because I
verily believe that the majority of the former were absolutely use-
less, and that the very exact application of the latter was preju-
dicial, by confining, in some degree, what ought to be discharged
with the utmost freedom.
Wounds of the brain, among writers on this subject, have also
generally made a distinct chapter; but the treatment of them is
so very little different from those which have been already re-
lated, that tjaey may fairly be comprehended under the same
article.
The brain is wounded either by the instrument, or body whereby
the scull is broken, or by broken parts of the cranium; foreign
bodies also, such as bullets, splinters, parts of weapons, wadding
of fire-arms, &c., are sometimes lodged in it; but let the wound or
fracture be what it may, or whatever other circumstances may
happen to attend, the chirurgic treatment is short and plain; viz.
to remove all such parts of the broken scull, as may press, wound,
or irritate the brain or its membranes; to take away all such
extraneous bodies, as can easily, and without violence, be got at
and extracted; and to make such an openyig as may most conve-^
niently serve the purpose of discharging blood, serum, or matter,
either in present or in future. When all these things have been
done, and the patient has been put under a proper regimen, both
of diet and medicine, the surgeon has done his duty, and may say
with Mr. Pope —
" Thv'.s i'nv was rij^lit ; llie rest we leave to heaven."
For with regard to the dressings proper in these cases, they are
not at all diflVn-ent from those which ought to be useJ, where
neither the brain nor its meninges are hurt. They should be soft,
light, and nol: consist of any tiling greas> , or which can possibly
PROM EXTERNAL VIOLENCE. 143
irritate or inflame; nor should they be applied in such manner or
quantity as to press or obstruct the free discharge of fluids of any
kind. Soft dry lint is perhaps equal to any or all others. In the
chirurgical writers are to be found a great many formulae: but,
whoever places confidence in them, for any supposed merit of their
own, will find himself much disappointed.
I cannot quit this subject, without making a short remark on
the bandages most frequently advised, and used in wounds of the
head.
In all the writers on the subject of fasciae are to be found de-
scriptions and delineations of those which are said to be most
proper for the head. On paper they are neat and elegant, in the
application they require a small degree of practice and dexterity,
and, when applied nicely, may impose on the ignorant, and on
those who have not seen much of, or reflected much on, their in-
convenience. They press, heat, and painfully confine the head,
even when applied in the best and most ingenious manner; and.
when put on awkwardly or negligently, are still more troublesome,
and less serviceable. All that can ever possibly be wanted in
these cases from bandage must be, merely to keep the dressings in
their place without any degree of confinement or pressure; and
this purpose will always be better accomplished by a loose cotton
or yarn night-cap, than by the nicest and most elaborate bandage
that ever was invented.^
y " On tliis subject I was very glad to find so very good a judge as Oriba-
sius of the same opinion.
" Hxc autem omnia non fasciis continentur, propter pondus, sed velamento,
*• ut cohibeantur, neque cerebri membrana gravatur ; ac velamenti media
" pars, quae terebrato respondet, forfice exciditur, ut apertum fiat, atque in
" illud spatium cana mollis, in extremis constricta, duplex inditur," &c.
•* Plerique omnes non alia vinctui'a terebratos deligant ; sed sola redemi-
"culi circumductione contenti sint. Quinetiam ipsa quoque ulcera extra
" terebrationem, quoad fieri potest, conari debemus sine fasciis curare ; non
•' modo quia gravantur compressis iis quae sub vinculis imposita ipsis fuerant^
" verum etiam quia plus quam par est califaciunt. Etenim quod in aliis par-
"t;Vius vinctura, id in capite positio praestabit, ideo deligare supervacaueum
^'erit."
OnriiAsivs DefraCt. ex Ileliodoro.
144 INJURIES OP THE HEA1»
CASE XXIX.
A GIRL, about fifteen years old, crossing Smithlield on a market-
day, was tossed by an ox, and fell with her head on the flat stones
within the posts. As her dress was mean, and nobody knew any
thing of her, she was brought senseless into the hospital. She had
a large bruise on the right side of her head, through which I
plainly felt a fracture with depression. The scalp being removed
from that part, the fracture was found to be large, and the depres-
sion considerable: it traversed the os parietale from before back-
ward, in its middle part between the sagittal and temporal sutures,
and the depression was of the upper part of the bone. I applied
a trephine on the inferior and undepressed part, and by means of
an elevator raised the whole to a perfect equality. Her head wa&
dressed lightly, and sixteen ounces of blood were taken from her.
She passed the following night very unquietly, and the next morn-
ing was still senseless. She was again freely bled, and a purge
was given, which soon operated. On the third day, her pulse
admitting, and her circumstances requiring it, she was bled again.
On the fourth day she became sensible, and on the fifth was sur-
prisingly well. She remained so until the ninth, on the evening
of which she complained of head-ach, sickness, and giddiness.
She was again let blood, and put under the direction of the phj'-
sician, who ordered some medicines for her. From the ninth to
the thirteenth day, she remained much the same; that is to say,
feverish, and complaining of heat, thirst, head-ach, and watching.
On the fourteenth she had a severe rigor, and the sore on the scalp
as well as the denuded dura mater wore a very bad aspect. From
this time she became daily worse and worse, in every respect; and
on the twentieth day from that of the accident, she died, having
been terribly shaken by spasms for several hours.
All the internal surface of the os parietale above the fracture
was detached from the dura mater, and covered with matter,
which could not obtain free discharge at the perforation, the mem-
brane being inflamed and thrust up tight against it.
I will not pretend to assert, that repeated perforation of the up-
per part of the bone would have preserved her; but I must say,
PROM EXTERNAL VIOLENCE. 145
as the case turned out, it would have been her best, if not her only
chance; and that, if I had known at that time as much of these
cases as I think I have since learned, I should certainly have taken
away the greatest part, if not the whole of what had been de-
pressed.
CASE XXX. .
A gentleman's servant, riding carelessly and hastily through
London, was thrown from his horse, and struck his forehead
against a sharp stone. There was a considerable wound on the
scalp, and a fracture, with depression of the os frontale. The
man was perfectly deprived of sense, the bone was considerably
depressed, and a large quantity of blood issued from underneath
the depressed part. A trephine was applied on the undepressed
part, and the elevation accomplished; he was let blood freely,
and dressed lightly. On the second and third days he was let
blood again. On the fourth he recovered his senses, and from
that day to the ninth seemed to go on well. On the ninth in the
evening he complained of pain and lassitude, and was ill that night
and all the next day. On the eleventh he was worse, and (to use
his own words) said, his brains were bound round with a fillet,
like a collar of brawn. His pulse was hard, frequent, and jar-
ring, his skin hot, and he got no sleep at all. As the man was
evidently and hastily getting into a hazardous state, I was de-
termined to try what a free removal of bone would do; and with a
large trephine took away almost the whole of what had been de-
pressed. The dura mater was not purulent, but dull in colour,
and smeared over with what Morgagni says is gelatinis instar.
He was again and again let blood, as his pulse would bear, and
the physician ordered proper medicines, for him. For four days
from this time he continued much the same, but after that every
thing changed for the better; he took the cortex freely, and in about
three months was discharged well.
As I would not pretend to assert, that removal of more bone
would have proved successful in the preceding case, so neither
will I say that the recovery of this man was owing to it. I can
VOL. I. T
146 INJURIES OP THE HEAD
only say, I verily b-^lieve both, and that I am sorry I did not
make the snme experiment in i)oth. The cases were materially
similar; and the analogical is the only method we have of reason-
ing on subjects like this, wherein we cannot have demonstration.
CASE XXXI.
A BOY, about fourteen years old, following a led horse, was de-
sired by the servant, in whose hand the horse was, to strike him;
the boy did so, and received a blow from one of the horse's heels,
which brought him to the ground senseless. He had on the upper
and middle part of his forehead a large wound, which disclosed a
considerable fracture, with depression.
The fracture ran nearly in a transverse direction across the
bone, and the depression was of the upper part. A trephine was
applied, an elevator introduced, and the depressed part of the
bone with some difficulty made to lie even. The head was
dressed lightly, and the boy was let blood largely. He continued
senseless all that night, was let blood twice the next day, and had
a purge and a clyster. On the fourth day he showed some signs
of sense; and in two more, being again let blood and kept very
low, was quite sensible. From this day until the fourteenth,
every circumstance was promising, but on that day he again be-
came ill; his pulse from this time was hard and quick, and, in
short, he had for three or four days all the symptoms of mischief
under the cranium. On the nineteenth I made a large perfora-
tion in that part of the bone which had been depressed and ele-
vated, and gave discharge to a very large quantity of offensive
matfer. On the twenty-second he became delirious and convuls-
ed, and on the twenty-third he died.
I removed all the upper part of the cranium, and found the
dura mater altered in colour, and separated from the whole frontal
bone, from the fracture quite up to the sagittal suture; and under
the said membrane, matter to the quantity of about half an ounce.
PROM EXTERNAL VIOLENCE. 147
CASE XXXII.
The following case was sent me by a very ingenious practi-
tioner at some distance from London, and may, among others of
like sort, sefve to prove that it is not merely the formation of
matter between the scull and dura mater, but also the confinement
of it there, which are the joint causes of the bad symptoms, and
of the hazard.
A boy fell from a cart loaded high with hay, and pitched per-
pendicularly on his head. The blow stunned him for a few mi-
nutes, but he soon got up again, said he was not hurt, and walked
home with the cart.
As he made no complaint at home, his master took no farther
notice of his fall, and the boy followed his daily labour in the
farm -yard.
At the end of a fortnight he came to my friend, and desired
him to look at the swelling on the upper part of the right side of
his head. The tumor appeared to be full of matter, and the sur-
geon divided the scalp, and let out a considerable quantity. He
passed his finger in, in order to examine whether the cranium
was bare or not, and was not a little astonished to find it not only
bare but considerably broken. He removed the tumid portion of
the scalp; and having so done, found the distinct pieces of bone
so loose as to be taken away without any resistance, and so large
as together to make nearly a third part of the parietal bone. The
dura mater under them was clean, and well incarned.
The boy had no one bad symptom from first to last, came to
the surgeon's house every day to be dressed, and was also in the
farm-yard daily.
148 INJURIES OF THE HEAD
SECT. VI.
EXTRAVASATION AND COMMOTION.
Great and hazardous as the evils are which proceed from frac-
tures of the scull, thej do not exceed those which are caused either
by the extravasation of fluids within its cavity, or by the concus-
sion or derangement of the substance of the brain; whether we
regard the difficulty under which a practitioner labours in form-
ing a judgment of the true nature of the case, or the uncertainty,
or the frequent fatality of the event.
The shock which the head sometimes receives by falls from on
high, or by strokes from ponderous bodies, does not infrequently
cause a breach in some of the vessels, either of the brain or its
meninges; and thereby occasions extravasation of the fluid, which
should circulate through them. This extravasation may be the
only complaint produced by the accident; or it may be joined
with, or added to, a fracture of the scull. But this is not all; for
it may be produced not only when the cranium is unhurt by the
blow, but even when no violence of any kind has been offered to,
or received by the head.
Vertigo, vomiting, stupidity, hsemorrhage, loss of sense and mo-
tion, either partial or total, are the symptoms of this kind of mis-
chief; sometimes one, or more, sometimes all, in the same sub-
ject. These symptoms, which are all easily accountable for from
extravasation of fluid, and unnatural pressure made on the brain
and nerves, are, as I have already at large remarked, frequently
mistaken as indications of a disease which, considered abstracted-
ly, can never cause them; I mean a simple undepressed fracture
of the cranium: it maybe accompanied by them, but cannot cause
them.
When a fluid is extravasated in any considerable quantity
within the cavity of the cranium, if any bad symptoms are pro-
duced by it at all, they are, and must be, such as indicate pressure
made on the brain and origin of the nerves; occasioning thereby
FROM EXTERNAL VIOLENCE. 149
either disturbance or abolilion of the offices of sense and motion;
and this in different degree, according to the quantity, kind, and
situation of the pressing fluid; and to these is sometimes added
haemorrhage from the nose or ears. Thus far, I think, we may
pronounce positively; but, to our very frequent mortification, we
find these are the only circumstances which in such case we can
depend upon, every thing else which relates or belongs to them
being involved in a most perplexing obscurity. We not only have '
no certain infallible rule whereby to distinguish what the pressing
fluid is, or where it is situated, but we are in many instances abso-
lutely incapable of knowing whether the symptoms be occasioned
by any fluid at all; for a fragment of bone, broken off from the
internal table of the cranium, and making an equal degree of
pressure, will produce exactly the same complaints.
Sometimes, indeed, the case is otherwise; and, from concomi-
tant appearances, the true nature of the disease may with some
degree of certainty be known; but this does not happen very
often.
Many of our ancestors, when no fracture was discoverable in
the cranium of a person labouring under such symptoms as have
been mentioned, in consequence of violence offered to the head,
contented themselves with calling the case a concussion; and
although they had no very precise idea annexed to the term, yet
they seldom went farther for a solution; like teeth and worms in
infants, or like nerves in women, it satisfied ignorant inquirers.
The cranium was not broken, the mischief was out of sight, most
probably out of reach, and they had not often the curiosity or the
anatomical judgment to examine after death into the real state of
the case.
That a concussion or commotion of the substance of the braia
is a circumstance which frequently happens, is a truth beyond all
doubt; and that it is often the cause of death, is as true; but that
many of the cases which, the scull being found not broken, have
passed for concussions, have been really produced by very diffisrent
causes, has often been incontestibly proved by the examination of
such persons' heads after death; where such extravasation of blood
or lymph, or both, have been found, as would fairly and ration-
ally account, both for the symptoms and for the event.
150 INJURIES OP THE HEAD
A concussion and an extravasation are very distinct causes of
mischief, though not always very distinguishable.
M. Le Dran, and others of the modern French writers, have
made a very sensible and just distinction between that kind and
degree of loss of sense which arises from a mere commotion of
the brain, and that which is caused by a mere extravasation, in
those instances in which the time of the attack or appearance of
such symptoms is different or distinct. The loss of sense,
which immediately follows the'violence, say they, is most probably
owing to a commotion; but that which comes on after an interval
of time has passed, is most probably caused by extravasation.
This distinction is certainly just and good, as far as it will go.
Thai degree of abolition or diminution of sense, which immedi-
ately attends or follows the blow or fall, and goes off again without
the assistance of art, is in all probability occasioned by the sudden
shake or temporary derangement of the contents of the head; and
the same kind of symptoms recurring again some time after they
had ceased, or not coming on until some time has passed from
the receipt of the violence, do most probably proceed from the
breach of a vessel within or upon the brain. Bus unluckily we have
it not very often in our power to make this exact distinction. An
extravasation is often made so immediately, and so largely, at the
instant of the accident, that all sense and motion are instantane-
ously lost, and never again return And it also sometimes hap-
pens, that although an extravasation may possibly not have been
made at the moment of the accident, and the first complaints may
have been owing to commotion merely, yet a quantity of fluid
having been shed from its proper vessels very soon after the acci-
dent, and producing its proper symptoms, before ihose caused by
the commotion have had time to go off, the similarity of the
effects of eacli^of these different causes is such, as to deprive us
of all power of distinguishing between the one and the other, or
of determining with any tolerable precision to which of them
such symptoms as remain are really owing.
When an extravasation of any kino i-^ made, either upon or
within the brain, if it be in such quantity, or so situated, as to
disorder the economy of the ariinid}. it always produces such dis-
order, by making an unnatural pressure on the pans where it lies.
*' FROM EXTERNAL VIOLENCE. 151
Tlie nature and degree of the syniptoms hereby produced are
various and different in different persons, according to the kind,
quantity, and situation of the pressing fluid. Sometimes it is
mere fluid blood, sometimes blood in a state of coagulation; some-
times it is a clear lymph, and at others blood and water are found
mixed together: each of these is found either simple or mixed in
different situations; that is, between the scull and dura mater,
between the dura and pia mater, or in the natural cavities of the
brain called its ventricles, and sometimes in cases of great vio-
lence, they are found at the same time in all these different parts.
Sometimes a considerable quantity is shed instantly, at the time
of the accident; and sometimes the breach by which the elfiision
is made is so circumstanced, both as to nature and situation, that
it is at first very small, and increases by faster or slower degrees.
In the former, the symptoms are generally immediate and urgent,
and the extravasation is of the bloody kind; in the latter, they are
frequently slight at first, appear after some litttle interval of time,
increase gradually till they become urgent or fatal, and are in
such case generally occasioned by extravasated lymph. So that
although the immediate appearance of bad symptoms does most
certainly imply mischief of some kind or other, yet, on the other
hand, no man ought to suppose his patient free from hazard, either
because such symptoms do not show themselves at first, or because
they appear to be but slight: they which come on late, or appearing
slight at first increase gradually, being full as much to be dreaded,
as to consequence, as the more immediately alarming ones; with
this material difference between them, that the one may be the
consequence of a mere concussion of the brain, and may by
means of quietude and evacuation go quite off; whereas, the
other being most frequently owing to an extravasation of lymph
(though sometimes of blood also) within the substance of the
brain, are very seldom removed by art.
Extravasations of any kind, and wherever situated within the
cranium, are very hazardous, and much more irequetitly end fa*
tally than happily; but considered as relative to the art of surgery,
that 'which consists of merely fluid blood situated between the
cranium and dura mater is certainiy thf; best, as it is the nearest to
the surface, and admits the greatest probability of being relieved
153 INJURIES OF THE HEAD
by perforation of the scull: grumousor coagulated blood, although
in the same situation, by being most frequently adhering to the
membrane, is not so readily discharged as the preceding, and
therefore more likely to prove destructive: and all those which
are either under the meninges, or within the cavities or substance
of the brain, as they are seldom within our exact knowledge, so
they are also generally beyond the reach of our art.
The method of treating people under these unhappy circum-
stances is somewhat different, according to the supposed or most
probable nature of the complaint, and according to the symptoms
and appearances which it produces, or which accompany it.
When the symptoms which imply a pressure made on the brain
or nerves have been occasioned merely by a shake or concussion,
and neither blow nor other external violence has been offered to
or received by the head, we have no rule whereby to form any
other than a general opinion; no mark which can point out to us,
either the precise nature of the disease, or its particular situation;
consequently, we have no direction from what part of the head to
remove the scalp, or where to apply a perforating instrument, and
therefore no warrant for perforating at all. In this case, the only
chance of relief is from phlebotomy and aperients; by which we
may hope so to lessen the quantity of the circulating fluids, as to
assist nature in the dissipation or absorption of what has been ex-
travasated. This is an effect, which, although not highly impro-
bable in itself, yet is not to be expected from a slight or trifling ap-
plication of the means proposed. The use of them must be pro-
portioned to the hazard of the case. Blood must be drawn off
freely and repeatedly, and from different veins; the belly must be
kept constantly open, the body quiet, and the strictest regularity
of general regimen must be rigidly observed. By these means, very
. alarming symptoms have now and then been removed, and people
in seemingly very hazardous circumstances have been recovered.
Instances of these successes are not indeed so frequent as we could
wish, but they have been sufficiently so to warrant the attempt,
especially in cases where there are no indications to authorise the
use of any other. But when the symptoms of extravasation are the
consequence of such external violence as leaves a mark where it
FROM EXTERNAL VIOLENCE. 153
was inflicted, and when the scalp is so bruised or wounded as to
shew the place where, we then have some degree of assistance,
both in forming a judgment of the most probable nature of the
complaint, and in using the means most likely to prove successful
in its relief. For if the effusion has been the consequence of the
stroke which the head has received, and such effusion is made im-
mediately under the part so stricken, the perforation of the cranium
in this place may give discharge to the extravasated fluid; and the
wound or bruise in the scalp shows us the point from whence we
ought to remove a portion of it, in order to perforate the cranium.
This I say is sometimes the case, and the consequence is some-
times so fortunaie that we save a perishing patient. But, al-
though it does now and then happen that we succeed, yet such
success is by no means certain or to be depended upon. Every
thing relative to this kind of disorder is fallible and uncertain; and
though the extravasation be sometimes found immediately under
the external mark, yet it often happens that it is not, and that the
effusion is made in a part distant from that mark, and to which we
have nothing to lead us. Upon the whole, although a bruise or
wound of the scalp does not in these cases necessarilj or certainly
point out the seat of an extravasation, yet whe« bad symptoms
urge, and evacuation has been fully and unsuccessfully tried, such
mark may be deemed a sufficient though not unerring authority
for making farther inquiry, by removing the scalp and perforating
the cranium: for this is a kind of case in which we are not to ex-
pect certainty, and in which we must be content with such inform-
ation as we can obtain. The opportunities which we have of
being serviceable are but few; we should therefore suffer none to
escape, but embrace even possibility. The general advice given
by Fabritius ab Aquapendente^ is applicable to no part of surgery
more than to this; in which the loss of a very short space of time
is often absolutely irretrievable.
* If the extravasation be of blood, and that blood be in a fluid state,
small in quantity, and lying between the scull and dura mater, im-
'■ " In vulnerib'js qnse natura sua admodum peviculosa sunt, pessimura est
"' expectare prava symptoniatii ; et tunc demum providere, cum torsitan
*' occasio prpeteriit, nee aniplius providere licet." Fab, ab AauAFESTDESTE.
VOL. I. TT
154 INJURIES OF THE HEAD
mediately under or near to the place perforated, it may happily be
all discharged by such perforation, and the patient's life may
thereby be saved; of which many instances are producible. But
if the event does not prove so fortunate, if the extravasation be so
large or so situated that the operation proves insufficient, yet the
symptoms having been urgent, general evacuation having been
used ineffectually, and a wound or bruise of the scalp having
pointed out the part which most probably received the blow; al-
though the removal of that part of the scalp should not detect any
injury done to the bone, yet the symptoms still subsisting, I cannot
help thinking, that perforation of the cranium is in these circum-
stances so fully warranted, that the omission of it may truly be
called a neglect of having done that which might have proved
serviceable, and, rebus sic stantibus, can do no harm. It is very
true, that no man can beforehand tell whether such operation will
prove beneficial or not, because he cannot know the precise na-
ture, degree, or situation of the mischief; but this uncertainty, pro-
perly considered, is so far from being a dissuasive from the at-
tempt, that it is really a strong incitement to make it; it being
full "as impossible to know that the extravasated fluid does not
lie between the scull and dura mater, and that under the part
stricken, as that it does; and if the latter should be ihe case, and
the operation be not performed, one, and most probably the only
means of relief, will have been omitted.
Morgagni, in his book De Causis et Sedibus, &c. has treated
this subject expressly, and has enumerated all the objections which
may be made to the perforation of the cranium, in the case of
effusion of fluid within it;» but among others he has mentioned a
^ " Nam ut signa sint, ex quibus liceat suspicai'i sanguinem intra calvariam
" esse effusiim, quis scire pro certo possit, an re vera ; et si hoc etiam sciret,
"in quam partem effusus sit, et quod consequitur, ubi et sit pertere'pran-
" dum," &c.
"Nam pretur iinum, qui majorem fortasse exterius dolorem moveat, alia
"esse possunt loca, sub quibus majus reveni lateat internum vitium.
"In cognoscendo quam fallaces ssepe sint conjecturse, vel hinc apparet,
" quod et si pars ipsa icta, ab segro indicatur, imo ecchymosi et tuniore se
"ipsam prjeclare indicet, non raro tamen casus incidunt, in quibus alia pars
" sit contusa, alia in quam effusio facta sit.
" Satis jam superque intelligis casus incidere, in quibus aut nulla, aut tan5
FROM EXTERNAL VIOLENCE. 155
popular one, which prevails much among his countrymen; viz. the
fear of having been thought to have destroyed those, whom in the
nature of things they could not save, " ne sic occisi, qui servari
" non potuerant, viderentur." With all possible deference to so
able a man, I must say, that this does not seem to me to be by any
means a good reason, or one which ought to be formed into a
maxim for practitioners: it is founded on the weakness and inca-
pacity of those who pretend to judge of what they do not under-
stand, and therefore should never be embraced through a self-in-
terested principle by those who know better. If such rule were
universally admitted, we should often be prevented from embrac-
ing a critical opportunity, or using what in many cases is the uni-
cum remedium^ not only in this disease but in many others. The
case of Ptolemy, cited by him from Livy, although brought as a
strong corroboration of his own opinion, really can prove nothing,
unless it could be made to prove that terebration was the cause of,
or at least accelerated, the patient's death; which it can by no
means be made to do. No man, who is at all acquainted with
this subject, will ever venture to pronounce or promise success
from the use of the trephine, even in the most apparently slight
cases; he knows that honestly he cannot: it is enough that it has
often been successful where and when every other means have
failed. The true and just consideration is this: Does the opera-
tion of perforating the cranium in such case add at all to that de-
gree of hazard which the patient is in before it is performed? or
can he in many instances do well without it? If it does add to the
patient's hazard, that is certainly a very good reason for laying it
aside, or for using it very cautiously; but if it does not, (which I
verily believe,) and the only objection made to it is, that it fre-
quently fails of being successful, surely it cannot be right to disuse
that which has often been not only salutary, but the causa sine qua
non of preservation, merely because it is also often unsuccessful;
that is, because it is not infallible.
*
" ]evia, inter Initia se offerunt, efFusi intra cranium sanguinis signa, tot autem,
" et tam gru%'ia post lorigum intervallum confestim se ingerunt, ut neque
" primo illo opportune tempore seger ex timore periculi, ut terebram admit.
" tat, neque extremo sperare possent medici, opem se per earn allaturos, tam
" longo spatio et tam perniciosis indiciis extantibus."
MoKGAGSi ite Caitsis et Sed. Morbor.
156 , INJURIES OF THE HEAD
I should be extremely sorry to say any thing which might mis-
lead my reader, but I cannot help thinking, that, dark and obscure
as this part of surgery is, yet there are sometimes appearances and
circumstances, which maybe said positively to indicate the fitness
of the operation, among which I reckon the spontaneous detach-
ment of the pericranium from the scull, in consequence of a heavy
blow, attended with symptoms of stupefaction or loss of sense.
Whenever the dura mater is separated from its attachment to
the inner surface of the cranium, the pericranium covering the
outer part of the same bone is generally detached also. When this
separation is produced by the formation of matter, in consequence
of inflammalion, the tumefaction of the scalp, which denotes this
effect, appears some days after the violence has been received, and
is always accompanied with a symptomatic fever. The effusion
of a considerable quantity of estravasated blood on the surface of
the dura mater, as it absolutely separates that membrane from the
bone, and cuts off all communication between that part and the
scalp, so it does in the same manner oblige the pericranium to
quit its attachment to the scull, of which I have remarked fre-
quent instances, and I have also most frequently observed, that
the blood in such cases has been coagulated, and very adherent
to the membrane. Now if this observation should be found to be
most frequently true, that is, if a detachment of the dura mater
from within the scull, by means of an extravasation, be found to
be most frequently accompanied by a detachment of the pericra-
nium on the outside, have we not thereby an indication both why
and where we ought to perforate? The operation may not be suc-
cessful, but desperation cannot be submitted to while there is the
most extreme degree of probability of being serviceable.
A free discharge by means of it may produce a cure, or it may
prove only a temporary relief, according to the different circum-
stances of different cases: the disappearance or even the allevia-
tion of the most pressing symptoms is undoubtedly a favourable
circumstance, but is not to be depended tipon as absolutely por-
tending a good event; either a bloody or limpid extravasation may
be formed or forming between the meninges, or upon or within
the brain, and may prove as certainly pernicious in future as the
more external effusion would have done had it not been dis-
FROM EXTKRNAL VIOLENCE. l.'i'V
eharged; or the dura mater may have been so damaged by the vio-
lence of the blow as to inflame and suppurate, and thereby destroy
the patient. The complaints arising from extravasation, and from
suppuration, are (as I have already at large observed) very diifer-
ent and distinct from each other; the former may be relieved, or
even totally removed, and the latter not prevented, nor indeed be
capable of prevention: of this every practitioner should be aware,
lest he expect and promise too much.
The nearer the extravasated fluid lies to the cranium the better;
therefore, that which is situated between the scull and dura mater
is, caeteris paribus, the most favourable of any. If the disease
lies between the dura and pia mater, mere perforation of the scull
can do nothing; and therefore, if the symptoms are pressing, there
is no remedy but division of the outer of these membranes. The
division of the dura mater is an operation which I have several
times seen done by others, and have often done myself; I have
seen it, and have found it now and then successful; and from those
instances of success, am satisfied of the propriety and necessity of
its being sometimes done: but let not the practitioner, who has not
had frequent opportunity of seeing these kinds of things, presume,
from the light manner in which this necessary operation has been
spoken of by a few modern writers, that it is a thing of little con;
sequence; for it most certainly is not. Wounds of the membranes
of the brain, by whatever body inJlicted, or in whatever manner
made, have always been deemed, and (which is more to the purpose)
have always been found to be hazardous. There is indeed some
difference between a wound made by a clean lancet or knife, and
one made by bone, bullet, or any thing which bruises or tears: but
this relates only to the manner : the part wounded is the same in
all; and whether the dura mater be divided by a lancet, or by a
fragment of bone, or any other body, it is equally divided, and the
air is let in in the same manner on the pia mater, or brain, which
become thereby subject to all the ills which such wound, or such
exposition, is capable of causing.
Authors, indeed, do every now and then tell us strange stories,
and give us strange accounts of incisions made into the meninges
and brain in search of foreign bodies, of extravasated fluids, &:c. :
but let the young practitioner read these relations with ^ome re-
158 INJURIES OF THE HEAD
serve of faith, and recollect that the excellent advice given by a
very able man, " Homines non admiratione afficere, sed eis utiliora
" docere," is not always attended to by writers. Caution and
fear are different things; where any good can be done, it ought to
be attempted by every practicable and justifiable means; but
where no good is reasonably to be expected, there is no warrant
for doing any thing. The division of the dura mater I have seen
to be necessary, and I have seen it to be successful: but all
wounds of it are far from being matters of indiflerence. Every
chance of life is to be embraced, and a good surgeon will never
hesitate to execute whatever appears feasible, or even possibly
beneficial ; but at the same time he will not act without some
such kind of warranty as shall prove that his patient's benefit was
his one object, and will take care that neither his prognostic nor
his conduct shall expose him justly to the censure of being either
ignorant, unfeeling, or fool-hardy.
Upon the removal of a piece of bone by means of the trephine,
if the operation shall have been performed over the part where
the disease is situated, and the extravasation be of the fluid kind,
and between the cranium and dura mater, such fluid-, whether it
be blood, w^ater, or bolh, is immediately seen, and is partly dis-
charged by such opening: if, on the other hand, the extravasation
be of blood in a coagulated or grumous state, it is either loose, or
in some degree adherent to the dura mater: if the former of these
be the case, it is either totally or partially discharged at the time
of or soon after the operation, according to the quantity or extent
of the mischief : if the latter, the perforation discovers, but does
not immediately discharge it. In both instances, the conduct of
the surgeon, with regard to repetition of the operation, must be
determined by the particular circumstances of each individual
case; a large extravasation must necessarily require a more free re-
moval of bone than a small one; not only on account of freedom
of discharge, but on account of larger detachment of dura mater;
and a grumous or coagulated extravasation requires a still more
free use of the instrument, not only because the blood in such stale
is discharged with difficulty, but because the whole surface of the
dura mater so covered is always put under the necessity of sup-
PROM EXTERNAL VIOLENCE. 150
purating, which suppuration has but one chance of a happj' event,
and that derivable from the free use of the perforator.
When the extravasation is not between the cranium aud dura
mater, but either between the meninges, or in the ventricles of
the brain, the appearances are not only different from the pre-
ceding state of the case, but from each other.
When the extravasated fluid lies between the scull and dura
mater, as soon as that extravasation is discharged, or the grumous
blood has been wiped off, ihe dura mater appears flaccid, easily
yields to or does not resist the impression of a finger, and (the
discharge being made) enjoys that kind of motion, that elevation
and depression, which our fathers supposed it to have naturally
and always, but which is only the consequence of the circulation
through the brain, and the artificial removal of the piece of bone.
But when the extravasation is situated between the meninges, or
on the surface of the brain, the appearance is not the same. In
this case, there is no discharge upon removing the bone; and the
dura mater, instead of being flaccid and readily obeying the mo-
tion of the blood, appears full and turgid, has little or no motion,
and pressing hard against the edges of the perforation, rises into a
kind of spheroidal form in the whole of the perforated bone. If
the extravasation be of the limpid kind, the membrane retains its
natural colour; but if it be either purely fluid blood, or blood co-
agulated, and the subject young, the colour of the membrane is so
altered by what lies under it, that the nature of the case is always
determinable from this circumstance.
Be the extravasated fluid what it may, it has no natural outlet;
absorption was the only chance the patient had whereby to get
rid of it without an operation, and that we must now suppose to
have failed; an artificial opening therefore must be made, by the
division of the dura mater, and perhaps of the pia also. This
operation, under the circumstances and appearances already men-
tioned, is absolutely necessary, and has been successful: it is per-
formed to give discharge to what cannot be got rid of by any
other means, and consists in a division of the membrane or mem-
branes, made in a crucial form with a point of a lancet. The
operation in itself is extremely simple and easy, but the patient is
thereby put into the state of one whose meninges have been
160 INJURIES OF THE HEAD
wounded, with only this difference, that the wound made for this
purpose is smooth and simple, and inflicted with the least possi-
ble violence; whereas an accidental wound of the same parts
may be lacerated, contused, and attended with circumstances
which must aggravate the evil, and may induce worse conse-
quences.
Of commotion or concussion of the solid parts of the brain, we
have only a negative kind of proof, and therefore are still more in
the dark, than we are with regard to extravasation.
Yery alarming symptoms, followed sometimes by the most fatal
consequences, are found to attend great violences offered to the
head; and upon the strictest examination both of the living and
the dead, neither fissure, fracture, nor extravasation of any kind,
can be discovered. The same symptoms, and the same event,
are met with when the head has received no injury at all ab ex-
terno^ but has only been violently shaken; nay, when only the
body or general frame has seemed to have sustained the whole
violence. It is a commonly received opinion, that a concussion
of the brain is always in proportion to the resistance which the
cranium makes; that if the latter sustains a considerable degree
of fracture, the former is but slightly injured, and that the con-
cussion is greatest when the scull is least hurt. This may some-
times be the case; violent and even fatal commotions of the brain
happen when no injury has been done to the scull, and very large
and terrible fractures are sometimes unattended with any symp-
toms of concussion; all this is sometimes true, but the position
can by no means be admitted as a general principle, whereon to
form our judgment, or whereby to regulate our conduct; experi-
ence frequently contradicting it.
The symptoms attending a concussion are generally in propor-
tion to the degree of violence which the brain itself has sustain-
ed, and which indeed is cognizable only by the symptoms. If
the concussion be very great, all sense and power of motion are
immediately abolished, and death follows soon: but between this
degree and that slight confusion (or stunning, as it is called)
which attends most violences done to the head, there are many
stages. Sometimes a concussion produces the same kind of
FIIOM EXTERNAL VIOLENCE. 161
oppressive symptoms as an extravasation, and the patient is either
almost or totally bereft of sense: at other times no such symploms
attend, but the patient gets no sleep at all, has a wild loolc, an
eye much like to that of a person who has long watched through
apprehension and anxiety, talks much and very inconsistently,
has a hard labouring pulse, some small degree of fever, and
sometimes an inclination to vomit: if not retained, the patient
will get out of bed, and act with a kind of frantic absurdity,
and appears in general much hurt by a strong light. A de-
bility of understanding, an ideot look, a failure of memory, a
paralytic affection of some one part or limb, the loss of sense,
spasm, resolution or rigidity of some one part or muscle, are
often the consequence of it. These complaints are sometimes
cured, but some of them do sometimes remain through the rest
of life.
To distinguish bet^yeen an extravasation and a commotion by
the symptoms only, is frequently a very difficult matter, some-
times an impossible one. The similarity of the effects in some
cases, and the very small space of time which may intervene be-
tween the going off of the one and accession of the other, render
this a very nice exercise of the judgment. The first stunning or
deprivation of sense, whether total or partial, may be from either;
and no man can tell from which. But when these first symptoms
have been removed, or have spontaneously disappeared; if such
^tient is again oppressed with drowsiness, or stupidity, or total
or partial loss of sense, it then becomes most probable that the
first complaints were from commotion, and that the latter are from
extravasation; and the greater the distance of time between the
two, the greater is the probability not only that an extravasation is
the cause, but that the extravasation is of the limpid kind, made
gradatim, and within the brain.
Whoever seriously reflects on the nature of these two causes of
evil within the cranium, and considers them as liable to frequent
combination in the same subject, and at the same time considers,
that in many instances no degree of information can be obtained
from the only person capable of giving it, (the patient,) will im-
mediately be sensible, how very difficult a part a practitioner has
to act in many of these cases, and how very unjust it must be tc
VOL. I. X
162 INJURIES OF THE HEAD
call that ignorance, which is only a just diffidence arising from tb^
obscurity of the subject, and the impossibility of attaining materials
to form a clear judgment.
When there is no reason to apprehend any other injury, and
commotion seems to be the sole disease, plentiful evacuation by
phlebotomy and lenient cathartics, a dark room, the most perfect
quietude, and a very low regimen, are the only means in our
power; and are sometimes successful.
Having in the preceding sheets frequently spoken of the tre-
phine, I have only to add, that if such operation be attended with
success, that is, if an extravasated fluid be thereby discharged, a
depressed bone elevated, matter which had been formed between
the scull and dura mater let out, or the inflammatory tension of
the membrane prevented, in such manner as to rescue the patient
from the danger he was in from such accident; in such cases, I
say, that the bare dura mater readily obeys the motion of the.
blood through the brain, and is freely elevated and depressed; by
degrees it loses its bright silver hue, and becomes purulent and
sloughy, and then casting off this slough, is covered by a granu-
lation of new flesh, of firm consistence and florid red colour;
moderate quantity of good matter is discharged daily, and the
new incarnation rises gradually through the perforation, until
it gets above the edges of it, when joining with that which
either has sprung from the surface of the bare cranium, or
which has thrown ofl" from thence a small exfoliation, they
together make a firm cicatrix. During all this time the patient
is generally free from fever or pain, gets good sleep, has a
natural appetite, and seems as near to being in health as his cir-
cumstances can permit.
On the other hand, if the mischief be such that all means prove
ineffectual, the appearances are very diflerent. The dura mater,
instead of casting otf a thin slough and incarning kindly, becomes
hard, tense, and foul; in a fevsr days it generally thrusts up an ill-
natured fungus, which, pressing hard against the edges of the per-
foration, prevents the discharge fiom within; the bare bone be-
comes blackish or deeply yeilou', and the edges of the sore in the
scalp are painful, loose, flabby, and have no connexion with the
bone on which they lie; the discharge is a thin stinking gleet, and
FROM EXTERNAL VIOLENCE, 163
large in quantity; the patient is hot, thirsty, and sleepless; the
tongue is black, the pulse hard and quick; sometimes a delirium,
and sometimes frequent spasms disorder and shake his whole frame;
his countenance is flushed and has a yellow tint, his eyes lose all
their natural brightness and seem sunk in their orbits; and his
rigors, which were at first slight and few, become more frequent
and more severe as his dissolution approaches. A slight degree of
these symptoms is sometimes got the better of by proper care and
treatment; but if they are far advanced, or run very high, we may
use the words of a very excellent writer on this subject, I mean
Berengarius Carpensis:'' Hie casus est de his ^ equibusnon evadunt
aliquij nisi nutu dei.
•> The sentiments of a very ancient writer on this matter are so very jast
and apposite, that I hope the reader will excuse the length of the quotation.
" Qui sanescere possunt, vel peinturi sunt, ex his conjicere est; plurimum
" quidem ex ipso vulnere, deinde ct ex reliquo corpore.
" Salubriter se habentium notae. sunt, ulcus non dolens, cerebdque mem-
" brana naturalem colorem, ac motum servans, et ulcus post suppurationem
" imminui. Pus album, sequale, modice crassum, non male olens. Ulcus quod
" initio album apparuit, post aliquodterapus vubescere, carnem milio similem
" producere, sqiiamulasque suis temporibus emittere ; sine perturbatione
" somnum capere ; sine febre esse ; cibum appetere ; assumpta digerere ;
" eequas excretiones fieri; glandulas, quse primis die!)us apparuerant, aut
" erysipelas cito dissolvi.
"Eos qui periclitantur cognoscere licet turn aspectu, turn ex lis qua
" vulneri cjeteroque corpori accidunt, et iis quae excernuntur. Color igitur
" plerumque languidus et permanens, periculosus, oculique concavi et ex-
" tantes, Sec. Ulcus dolere, magis interdiu, retorridum fieri, atque omni ple-
■" rumque tumore carere, vel saniem manuai-e tenuem ac male olentem ;
" orasque sectae carnis admodum rubras et flaccidas esse, atque ubi magis
" reflexee sint, tunc abscedere cutem ab osse molestum est, membranamque
" vulneratam immobilem esse, exalbidam vel lividam apparere, vel nigram,
" vel plurimum inflammatum aut procidentem, purgatamque, iterum sponte
•' non ob aliqua re externa sordcscere."
Oribasius De Si^nis.
" Spem vero certain faclunt, membrana mobilis ac sui coloris, caro in-
"crescens rubicunda, facilis motus maxillEe, atque cervicis.
" Mala signa sunt membrana immobilis, nigra vel livida, vel aliter coloris
" corrupli, dementia, acris vomllus, nervorum distensio vel resolutio. — Caro
"livida, maxillarum atque cervicis rigor."
Cf-tscs.
164 INJURIES OF THE HEAI*
CASE XXXIII.
A YOUNG fellow, about twenty-four years old, was thrown by
the swing of a crane at the water-side from a window two stories
high, and pitched his head on a sugar hogshead. He was taken
up senseless, and brought in that state to St. Bartholomew's hos-
pital-
He was immediately let blood freely, and his head being first
clean shaved, was very carefully examined, but no external mark
of violence was found. Next morning he was bled again, and the
same operation was repeated in the evening of that day, and twice
in the course of the third. On the fourth day both the temporal
arteries were opened, and bled freely. On the fifth day he died,
his symptoms not having remitted in the smallest degree. The
cranium was perfectly uninjured. The dura mater every where
adherent, and no fluid of any kind between it and the scull. Be-
tween the dura and pia mater was a considerable quantity of fluid
blood, and principally toward the lower part of the brain,
CASE XXXiV.
A HACKNEY coachman was thrown from his box in Holborn,
and fell on his head, as it was thought. He became immediately
insensible, and was brought so to the hospital. No mark of vio-
lence was to be found on any part of his head, and therefore, al-
though his symptoms were such as rendered an extravasation
most probable, yet there was no reason for setting on the instru-
ment on any particular part. Every thing was done for him, both
by the physician and myself, from which any advantage might
reasonably be expected; but on the third day he expired, having
never showed any signs of sense.
All the space between the frontal bone and the dura mater was
covered with grumous blood, firmly adherent to the latter.
FROM EXTERNAL VIOLENCE. 165
CASE XXXV.
A bricklayer's labourer fell from a high scaffold, broke one
arm and one thigh, and was brought to the hospital about two
hours afterward in a state of stupidity. When his arm and thigh
were put to rights, his head was examined, but no mark of mis-
chief discovered. He was bled freely, and stools procured on
each day for four successive days: but he continued in the same
state. On the fifth a small tumor arose on the right side of his
head. The scalp was removed, and the bone being found bare,
it was immediately perforated. The perforation made way for a
large discharge of blood which had been contained between the
dura mater and scull. On the first and second day from this ope-
ration he remained the same; blood was drawn from some part of
him on each, and the discharge continued large and free through
the opening made in the bone. On the third day from the appli-
cation of the trephine, he became toward evening somewhat sensi-
ble. On the fourth, having taken a laxative medicine, he had a
smart purging, which lasted some hours. On the sixth he was
quite calm and sensible, but being reduced to a very low state by
his free and frequent evacuations, it was thought right to give him
the cortex. This agreed well with him, and from this time he had
no other difficulty or trouble.
CASE XXXVI.
A BOY, about ten years old, climbing up a ladder, which was
set too perpendicularly, fell from an height of more than twenty
feet; he lay some time before he was found, and then was carried
home perfectly void of sense. In about three hours after the ac-
cident I saw him. He lay quite stupid and senseless, now and
then vomited, had a hard, full, labouring pulse, and an obstructed
respiration. No mark of violence appeared on his head. He was
bled freely, and had a stimulating clyster, which procured a free
discharge. During three days he was let blood twice a day; on
166 INJURIES OF THE HEAD
the fourth, a small degree of tumefaction appeared on the right
side of his head near to the sagittal suture; it was not very mani-
fest, neither did it appear to contain any considerable quantity of
fluid, but the very desperate circumstances the child was in, in-
duced me to open it, and, finding the scull bare, to perforate.
The dura mater was covered with blood, which discharged freely
both at the time of the operation, and during all the next day. On
the third day from the operation, he was still insensible. A se-
cond perforation was made just below the first, and a third on the
other side of the suture. Blood was discharged freely from all
three. He was dressed lightly, and his pulse being still strong,
more blood was drawn from one of the jugulars. The next day
he was rather better, but far from sensible. The day following
that he recovered his understanding, and could make signs for
what he wanted. It was near a week more before he got his
speech, but in the end he got perfectly well.
CASE XXXVII.
- A BOY between three and four years old, the son of a merchant
in my neighbourhood, was at play with his brother on a bed, and
fell from thence on a soft bedside carpet. He pitched on his head,
and complained immediately of being sick and giddy, but having
vomited, was soon after so well that no farther notice was taken
of his fall. On the fourth day from this, his sickness and giddi-
ness returned. Dr. Lee was sent for, who, not regarding the fall
as having any share in his complaint, gave him an emetic, and or-
dered him some of those medicines which are called nervous. For
the space of five days from this time, he continued to be now and
then sick and giddy, and was very unwilling to stir, or be stirred.
On the eleventh he complained that he could not see, and that
evening had a sort of fit. On the thirteenth his right arm be-
came useless. On the fifteenth he could not stand. From this
evening he became stupid; and on the eighteenth expired.
Between the dura and pia mater was a considerable quantity
of bloody serum about the basis of the brain.
PROM EXTERNAL VIOLENCE. 167
CASE XXXVIII.
A WOMAN came to my house, complaining that her husband had
kicked her down stairs, and had broke her scull. On the back
part of her head was a small wound, but the pericranium was not
divided, nor was there any reason to suppose the bone to be hurt.
For twelve days she remained without any general complaint; but
on the thirteenth she began to be giddy and dim-sighted,
I took her into the hospital, where she was taken all possible
care of; but she became first paralytic, and then comatose, and so
died. The ventricles of the brain were full of extravasated serum,
and, near the origin of the medulla oblongata, was a large lump of
firmly coagulated blood.
CASE XXXIX.
A carpenter's labourer in Blackfriars fell from a scaffold of a
considerable height, and in his way down struck a piece of tim-
ber, which, following him, hit him on the head. The man fell on
his breech. He was brought to the hospital senseless. The mark
on his head made by the timber was scarcely visible, and did not
imply any mischief underneath. He was freely let blood, and his
body emptied by a clyster administered that day. The next day
more blood was drawn from one jugular; and the third the same
operation repeated. On the fourth he spake, and on the fifth was
so sensible as to give an account of the place from whence he fell.
On the sixth, seventh, eighth, ninth, tenth, and eleventh, he was
free from complaint, except on the two last he was too much in-
clined to dose. On the twelfth he found some difficulty in pro-
nunciation, and said, that it was with great difficulty that he could
keep himself awake. As his pulse would very well bear it, more
blood was drawn away by opening the temporal artery, and a blis-
ter was applied to his neck. On the fifteenth he could hardly
speak at all, and was never awake unless disturbed for that pur-
pose. On the eighteenth he lost the use of his left side, and on
the twentieth died.
168 INJURIES OF THE HEAD
About the lower part of the brain was found a small quantity
of bloody serum, and all the ventricles were filled with a clear
lymph.
CASE XL.
A BOY about fifteen was thrown over the head of a horse, who
fell down with him in Smithfield. There was on the side of his
head a large wound, with a bare parietal bone; and although there
was no appearance of fracture, yet the violence having been great,
and the boy being perfectly stupid, I immediately perforated the
bare bone, suspecting an extravasation on the dura mater. That
membrane was perfectly fair and adherent, nor was there any
appearance of extravasation either upon or under it. The next
day he was still insensible. I examined the membrane again
very carefully, in order to see whether there was any sufficient
reason for dividing it, but could find none. Blood was drawn
from different parts in large quantity, but to no purpose; he lived
three days as it were in a deep sleep, and then died. There was
no injury done to the scull; no extravasation of either blood or
serum, either upon or between the membranes, nor any unnatural
appearances in the cavities of the brain: but upon the plexus cho-
roides was a lump of coagulated blood, near as big as half a small
chesnut.
In the course of these papers I have more than once said, that
although the symptoms arising from pressure made on the brain
and nerves, or on the meninges, were uniform and clear, and per-
fectly distinct from those caused by inflammation, yet that they
very seldom indicate what kind of bodv such pressure was made
by; whether blood, water, or bone; and consequently, that though
the disorders proceeding from pressure were perfectly distinguish-
able from those caused by inflammation, yet they were not at ail
or very seldom so with regard to each other. Some of the imme-
diately preceding cases are proofs with regard to blood and lymph.
PROM EXTERNAL VIOLENCE. 169
and what follow will, I think, in some degree, prove that the symp-
toms are the same when they are caused by bone, or by blood and
bone together.
CASE SLL
A CHILD about nine years old received a blow from a cricket-
bat on the upper part of his forehead, which brought him to the
ground, and deprived him of sense. I found him with a consi-
derable tumor on his forehead, and considering the state he was
in, would have removed immediately a part of the scalp; but a
dabbler in surgery, who was a relation, undertook to cure him by
an application. On the third day I was sent for again, and found
him nearly in the same state as I left him. I divided the scalp,
and found a fracture with depression. By means of the trephine
and elevator, the depressed part was raised, and the dura mater
being found in a very good state, and no apparent extravasation in
the case, nothing more was done at that time. Proper medicines
were ordered to procure stools. The next day his symptoms were
the same, except that his pulse was less labouring, and he had not
the apoplectic stertor, which he had till then. I examined the
bone, which lay perfectly smooth, nor was the dura mater at all
elevated into the perforation. Blood Tvas freely drawn from the
temporal arteries, and a stimulating clyster administered. On the
fifth day no alteration. I applied a trephine in the middle of that
part of the bone which had been depressed and elevated.*^ The
dura mater was thinly covered with gruraous blood, which being
gently wiped away, more of the same appeared; for two or three
days this discharge continued in small quantity; the boy gradually
recovered his senses, and in due time got well.
<= As this portion of bone must have been moveable, or unfirm, the opera-
tion must have been difficult. Without doubt, so experienced an operator
as Mr. Pott took care to have the portion of bone properly supported by an
assistant, with an elevator. E.
VOL. I. V
170 INJURIES OF THE HEAD
CASE XLil.
A YOUNG woman was thrown out from a country waggon, upon
a broad flat pavement, and was said to have pitched upon her
head. She was instantly deprived of sense, and brought to the
hospital in that state. Her head was immediately shaved and
examined, but found to be so absolutely free from all mark of vio-
lence, that 1 was in doubt of the truth of the account given of her.
She was freely let blood, and some medicines directed to be got
down, in order to empty her. The next day she was in the same
state. More blood was drawn off, and her cathartic repeated.
The third day, she being exactly the same, both the temporal ar-
teries were opened. On the fourth, there being no alteration, I
determined to apply a trephine on that part of her head, on which
she was said to have fallen, and which when pressed hard seemed
to produce such motion in her as if it gave some pain. In a case
of less necessity this would hardly have been sufficient reason:
but here something was to be attempted. I removed a large piece
of scalp, and found the pericranium, though not detached abso-
lutely, yet not naturally or firmly adherent. I applied the tre-
phine, and when I had worked a few seconds, I took out the
instrument to clean it, but was much surprised to find in it a piece
of the upper table of the scull. I put in my finger to feel what
was underneath, and found that it touched the remaining table,
which receded from the finger, and returned again upon removing
it; and when I pressed the said loose piece hard, the girl's whole
frame was spasmodically agitated. What was to be done .'' It
appeared to me, that if all her symptoms were not caused by the
pressure of the loose piece, yet they were certainly aggravated by
it, that it must therefore be taken away at all events, and that it
was much too large to be extracted at the present opening: beside
\vhich, as it ran upward toward the sinus, I should not have cho-
sen to run the risk of an hasmorrhage from thence while the sinus
was covered with bone. I perforated all round the present open-
ing with a small trephine, in such manner, that each perforation
so bordered on the other as that the whole- should make one
opening.
FROM EXTERNAL VIOLENCE. 171
For near one half the circle the outer table only came away in
tlie instrument, leaving the inner loose and covered with blood,
but in all the lower part the trephine went through both tables,
and left the dura mater covered with grumous blood also. When
tlie circle was finished, the loose portion was easily taken away;
its upper part made a part of the sagittal suture, but no blood fol-
lowed its separation. The dura mater under the whole was
thinly covered with grumous blood. Next day she retained her
urine, and opened her eyes. In two more she recovered her
speech, and became as rational as I suppose she ever had been;
and would in all probability have done well, as far as regarded
the evils produced by mere pressure; but after some days matter
formed between the detached dura mater and the scull, and the
symptomatic fever usually accompanying such mischief came on
with such rapidity, that all the efforts of art were vain.
CASE XLIII.
A PORTER, at work at the water side, was knocked down by a
blow from an iron hook, at the end of the tackle belonging to a
crane. He was senseless for near half an hour, but after that was
so well as to walk home. The next morning he lost his sight,
and by the evening his speech and faculty of walking. In this
state he was brought to the hospital. He was largely let blood,
and thoroughly emptied; and I intended, if these evacuations did
not materially serve him, to have examined the state of that part
of the bone whereon the blow was received; but that night he
died.
Upon examining his head, a piece of the inner table of the
right OS parietale, of about an inch and half in length, and not
quite SO broad, was found detached from the outer table, having
a quantity of blood both between them and on the surface of the
dura mater.
These are the only instances which I have met with of fracture
of the internal table alone; though I make no doubt, that some of
those who have been said and thought to have been destroyed by
concussion, have sunk under this kind of mischief.
OBSERVATIONS
THAT DISORDER OF THE CORNER Of THE EYE,
eOM:]»LOM.Y CALLKD
FISTULA LACHEYMALIS.
PREFACE.
By frequently conversing with some of that part of the profes-
sion who come to London to attend the hospitals, and to improve
themselves in the art of surgery, it has appeared to me that the
FISTULA LACHRYMALis, though a Very common disease, is one
with which many of them are very little acquainted, either with
regard to its cause, seat, or method of cure. Some are totally
ignorant of every thing relating to it: others, who have an imper-
fect idea of its nature and seat, are yet much at a loss how to vary
the method of treating it, according to its different states and
circumstances; upon which distinction the probability of a cure
does often in great measure depend; for if those means which
are only proper in one state of the disease be used in another, the
patient will be fatigued to no purpose; and the surgeon, by being
frequently disappointed, will be inclined to think those cases in-
curable, which have only failed through his own mismanagement.
There is hardly any chirurgical disorder which requires a more
close regard to all its appearances and variations than this does;
and whoever expects to conduct it successfully, must attend to it
constantly. This is, perhaps, the great reason why it is so little
understood; the object is too minute, and the process often too
long, to engage the attention; besides which, it hardly comes ,
under the name of an operation, the great and almost only object
176 PREFACE.
which they who come hither from the distant countries have in
view: the operative part of surgery is what they have seen the
least of, and therefore they are the more desirous of becoming
acquainted with it: this desire is a very laudable .one, and ought
certainly to be encouraged, but still the operative part of surgery
is far from being the whole of it; and I cannot help thinking, that
by attending a little more to what is called common or practical
surgery, our art might still be considerably improved, practition-
ers rendered more expert, and mankind much benefited.
The merely curing diseases is not all: that was done (sooner or
later) while surgery and anatomy were in their most imperfect state,
and while every branch of medicine laboured under many incon-
veniences which are now happily removed; but the different
methods in which chirurgical disorders are treated, or their cures
attempted, will make so considerable a difference in the confine-
ment and sufferings of the patient, as to be very well worth
attending to.
' It may possibly be thought foreign to my present purpose, but I
cannot omit this opportunity of adding a few words on a subject
which appears to me highly deserving of some notice, as its influ-
ence may be very extensive and very prejudicial; it is the false idea
which the by-standers at an operation generally have of chirurgic
dexterity; to which word they annex no other idea than that of
quickness. This has produced a most absurd custom of measuring
the motion of a surgeon's hand, as jockeys do that of the feet of a
horse, viz. .by a stop-watch; a practice which, though it may per-
haps have been enrouraged by operators themselves, must have
been productive of most, mischievous consequences. Tuteetcele-
riter are both very proper characteristics of a good chirurgic ope-
ration; but tute stands, as it should do, in ihe first place; as the
patient who suffers the smallest 'njury from the hurry of bis ope-
rator, has no recompense from the reputation which the latter ob-
PREFACE, 177
tains from the by-standers. In most of the capital operations,
unforeseen circumstances will sometimes occur, and must be at-
tended to; and he who, without giving unnecessary pain from
delay, finishes what he has to do in the most perfect manner, and
the most likely to conduce to his patient's safety, is the best ope-
rator.
I have endeavoured to make the following tract as plain and as
intelligible as I can; and, if it should appear prolix to those who
are already acquainted with the subject, I must beg leave to ob-
serve, that it was not written for their information; but if any of
those who were unacquainted with it before, should from hence
gain any useful knowledge, my end -will be answered, and I shall
be much gratified.
VOL. I.
OF THE
FISTULA LACHRYMALIS.
SECTION I.
The ancient writers were in general so little acquainted with
the anatomical structure of the parts concerned in this disease,
that both its cause and seat have been very erroneously repre-
sented by most of them; other disorders, very different both from
this and from each other, have been confounded under the same
general appellation ; and the means made use of toward obtaining
a cure, being adapted to such misconceptions, were rough, pain-
ful, and most commonly ineifectual.
The fluid which perpetually moistens the eye, was supposed to
be secreted by that small eminence in the inner angle, now called
the caruncule, and to flow from thence upward through the puncta
lachrymalia.* The caruncule was by many thought to be the seat
of the disease in question, which was said to be produced, either
« Fallopius, who has very accurately described the puncta lachrymalia, sac-
culus, and duct, as well as the disease, has yet fallen into this common error.
" Ad occulos ipsos ex faucibus egrediens yenio, in quibus primum psetermisere
" anatomici duo foramina parvain angulo interna posita, quarum, unum est in
•' palpebra superiori, alterum in inferiori, in viventibus adhuc hominibus, si
" quis inspicere voluerit apparentia, quje foramina habent meatus qui sub
" caruncula encanthidos vel epicanthidos dicta uniuntur in quendam com-
" munem sinum in narium cavitatera desinentem per canalem proprium in
" osse squamoso, quod internum angulum occupat insculptum.
" Per hos meatus major lachrymarum pars ut ego in fletibus mulierum
i' observavi, ad occulos emanat."
TalloviV9,
180 • OBSERVATIONS ON THE
bj a defliixlon from the brain'' on this part, or by an abscess
formed within the body of it; or, by a lodgement of the tears, be-
came acrid and corrosive in consequence of such stagnation;*^
while others looked upon it as a kind of encysted tumor. The
swelling in the inner corner of the eye, the frequently -attendant
ophthalmy, t{ie involuntary flux of serum down the cheek, the ex-
coriation of the eye-lid, and the discoloured discharge upon pres-
sure, strengthened their opinions, and confirmed their prejudices.
They who supposed it to be caused originally by a defluxion
of the inflammatory kind, tending to produce an abscess, had
recourse at first to those general - ethods and means which were
thought most likely to prevent such consequence: these not an-
swering, they proceeded to open the supposed abscess, and to
endeavour the digestion of it: on the other hand, they who sup-
posed it to be an encysted tumor attempted the eradication of it
*• Non enim os solummodo cariosum, verum etiam glan;lula ita erosa erat,
" ut quotiescunque puer ploraret, lachrymae per ipsam fistulam copiose ex-
" tillarent."
HlLDANUS.
'■ " Fistula lachrymalis sit ex humorum decursu, qui currunt ad lachvymalis
" angulum juxta nasam, nee propter eorum multitudinem, et grossitatem
" possunt exire, &.c. hi autem morantes ibi diutius corrurapuntur, et locum
" ulcerant."
Lakfranc.
" JEgylops est tumor abscessorius inter majorem angulum, et nares pro-
"veniens."
Pauius.
*■■ "At the gi'eat corner of the eye there is a glandule made for receiving
" and containing the moisture which serves for lubricating the eye ; this
" glandule sometimes, by a sanguine or pituitous defluxion falling violently
" from the brain, swells and impostumates, and ulcerates," &c.
Amb. Parey.
" Hsec caruncula ab acrium humorum affluxu turget, nonnunquam intu-
" mescit, et abscedit ulceraturque, ulcere. non raro in fistulam abeunte, adeo
"ut subjectum os corrumpatur."
MuNJflCKS.
•'Per pusillum utriusque palpebrse foramen lachrymals naturaliter ef-
" fluunt."
Fab. ab. AdtrAPENDEUTE.
"Lachrymx veniunt per lachrymalia a foramine quodam parvo, et quasi
*' insensibili in fine pilorum."
GUIDO.
FISTULA LACHRYMALIS. 181
either by knife, caustic, or cautery; and all of them taking it for
granted, when the discbarge was apparently purulent, or much
discoloured, that the bone was rotten, advise the use of escharotic
applications, or the hot iron, to destroy the callosity, and to dry
and exfoliate the caries; and these methods failing, as in the
nature of things they very frequently must, they pronounced the
disease to be incurable.
A more minute and careful examination into the anatomy of the
parts has given us a more true idea of the disorder, and furnished
us with a more rational, as well as a more successful, method of
treating it. We now know that the caruncule is not the organ
which secretes the tears, but that this office is performed by a
gland, situated near the outer corner of the eye; that the lach-
rymal fluid is in its nature perfectly innoxious; that an obstruc-
tion in the nasal duct is most frequently the primary and original
cause of the complaint; and that its seat is in the sacculus
lachryraalis.
Upon these principles the modern practitioners have, with
great industry and ingenuity, endeavoured to find out some means
whereby this obstruction may be removed, and the parts restored
to their natural and healthy state, without such pain, destruction,
and deformity, as the ancient methods occasioned; or, these fail-
ing, to establish a new artificial passage, . which may in some
measure supply the place of the natural one.
All these means have the merit of being founded on the
natural structure of the parts concerned. When the more
easy and mild ones succeed, the patient gains a considerable
advantage; and when they do not, little time is lost, nor is any
more efficacious method rendered thereby less practicable: in
this, as in every other part of surgery, the more simple means
ought to be first tried; pain should be avoided as much as possi-
ble, except when absolutely necessary, and then it must be sub-
mitted to.
182 OBSERVATIONS ON THE
SECT. II.
That the motions of the eye-lids may be performed with the
utmost ease, that the tunica cornea may be kept constantly clean,
bright, and fit for the transmission of the rays of light, and that
dust, and other hurtful particles, may be immediately washed
away, the surface of the eye is continually moistened by a fine
limpid fluid.
This fluid is derived principally from a large gland, situated
under the upper edge of the orbit near the outer corner of the
eye, which gland is of the conglomerate kind, and lies in a small
depression of the os fi-ontis; its excretory ducts, or those by which
it discharges the secreted fluid, piercing the tunica conjunctiva,
just above the cartilaginous borders of the upper eye-lids.
While the caruncule was thought to be the secretory organ of
the tears, this gland bore the title of glandula innominata; but
now that its use and office are known, it is called glandula lachry-
malis.
By irritation from any sharp or poignant particles, a large
quantity of this fluid is immediately secreted, and by the motion
of the eye-lids is as immediately derived over the surface of the
eye, by which means such particles are waslied and wiped off".
Sometimes also the passions of the mind produce an immediate
increase of this lymph, which is then strictly and properly called
tears; a constant secretion of too large a quantity causes a disease,
called epiphora; and a deficiency of it makes the motions of the
lid difficult and painful.
Although the fluid secreted by the lachrymal gland is consider-
able in quantity, yet when it is not suddenly produced by irrita-
tion from without, or passion within, it is so constantly and gradu-
ally carried off", as to create neither trouble, uneasiness, nor
blemish.
The edge, or border of each eye-lid, is formed by a thin carti-
lage, the figure and consistence of which keep the lids properly
expanded; these cartilages are covered by a fine membrane, and
are called cilia; their internal edges do, upon every motion.
FISTULA LACHRYMALIS. 183
sweep over every point of the surface of the cornea; this motion,
though almost imperceptible unless attended to, is very frequently
performed; and as the secretion of the fluid is also constant, the
eye is by this means kept always moist, clean, and bright.
At the extremity of each of these cartilaginous borders of the
eye-lids, on the side next the nose, is the small papilla, or emi-
nence; and in the middle of each of these is a small hole, or
perforation, which being made in the cartilage is not liable to
collapse while the parts are in a sound state, but remains always
open; they are called the puncta lachrymalia, and their office is
to receive the lachrymal fluid, as it runs off" the corner along the
edges of the eye-lids, thereby preventing it from trickling down
the cheek; and that there may be no impediment to the constant
execution of this office, during the time of sleep, as well as that of
being awake, the internal edges of the cilia do not come into
immediate contact with each other in that point where these
orifices are.
From each of these puncta lachrymalia proceeds a small mem-
branous tube, which tubes soon enter into, or form a pouch or bag,
situated near the inner angle of the eye, just below the union of
the two lids, under the musculous orbicularis palpebrarum; the
bag is called the sacculus lachrymalis, and its office is to receive
all the lymph brought by the puncta and ducts: the upper part of
this sacculus lies in an excavation, formed partly by the nasal
process of the os maxillare superius, and partly by the os unguis;
the lower part of it is confined in a long channel, and forms a
tube, or duct, which descending obliquely backward communi-
cates with the cavity of the nose, behind the os spongiosum supe*^
rius, by an opening whose size is somewhat different in different
subjects.
This passage is called the ductus ad nares or the ductus nasalis,
and through it whatever is received by the sacculus from the
puncta, does, in a healthy and sound state of these parts, pass into
the nose.
The membrane which lines this sacculus and duct, is in its
structure much like to the membrana pituitaria narium, from the
surface of which a clear viscid mucus is secreted, and by which
184 OBSERVATIONS ON THE
the sacculus and passages are constantly moistened and kept per-
vious.
While the parts are in a healthy sound state, the fluid se- -
creted by the lachrymal gland passes off through the puncta, sac-
sulus, and duct, into the nose, without any trouble; but when they
are in a diseased state the case is otherwise. This membrane,
like all other vascular parts, is liable to inflammation, by which
means it often happens that it is so thickened as to obstruct the
nasal duct, and thereby much impede, or totally hinder, the pass-
age of any thing through it; in consequence of which obstruction
the sacculus is filled by its natural mucus, and the derivation of
the serum from the lachrymal gland through it being thus pre-
vented, it runs off from the eyelids down the cheek: this obstruc-
tion continuing, and the mucus still lodging, the sacculus is dilat-
ed, and produces that tumor in the inner corner of the eye, and
that discharge, upon pressure, which characterise the first state of
the disease in question, and, in conjunction with several other
attending symptonis, prove its seat to be in the lachrymal sac,
and nasal duct.
SECT. III.
Although the seat of this disease is the same in almost every
subject, yet its appearance is very diflerent in different persons,
and under different circumstances. These variations depend
principally on
1. The degree of obstruction in the nasal duct.
2. The state of the cellular membrane covering the sac.
3. The state of the sacculus itself.
4. That of the bone underneath.
5. The general state and habit of the patient.^
^ As the state and circumstances of this disease are really various, and dif-
fer very essentially from each other, the general custom of calling' them all
by the one same of fistula lachrymalis is absurd.
' FISTULA LACHRYMALI3. 185
Sometimes a serous kind of d^fluxion, by which the lining of
the sac and duct is so thickened as to obstruct, or prevent, the
passage of the fluid through them into the tiose, makes the whole
complaint; and the cellular membrane on the outside not being dis-
eased, there is no appearance of inflammation. In this case the
duct is stopped, and the sacculus dilated, but without any altera-
tion in the colour of the skin; a fulness appears in the corner of
the eye next to the nose; and upon the application of a finger to
this tumor, a clear viscid mucus is discharged through the puncta
lachrymalia: the patient feels no pain, nor finds any inconve-
nience, except what is produced by the discharge of this mucus,
and by the trickling of the lymph down (he cheek.
In some cases the mucus is not perfectly and always clear, but
it is sometimes cloudy, and looks as if it had a mixture of milk or
cream in it: at first waking, some of it is generally found in the
corner of the eye; and the eye-lashes, being smeared over with it
during sleep, most commonly adhere together in the morning.
This is the most simple state of the disease, what the French
have called the hernia, or hydrops sacculi lachrymalis: it is fre-
quently met with in children who have been rickety, or are sub-
ject to glandular obstructions; and in this sfate it sometimes re-
mains for some years, subject to little alterations, as the health or
habit shall happen to vary, the sacculus being sometimes more,
sometimes less full, and troublesome; the mucus which is pressed
out is sometimes more, sometimes less cloudy, and now and then
it is attended with a slight ophthalmy, or an inflammation of the
eye-lids, but which by common care is easily removed.
When the sacculus is not much dilated, the discharge small,
and produced only by pressure, the chief inconveniences are the
weeping eye, and the gumming together of the lids, after sleeping:
but these, by being attended to, may be kept from being very
troublesome; and if the disease makes no farther progress, may
be so regulated as to render any more painful process totally un-
necessary.
When the dilatation is considerable, the swelling is more visible,
and the quant ty of mucus is larger: it is also in this state more
frequently mixt and cloudy, and more troublesome, from the more
frequent necessity of emptying the bag. But if the patient be
VOL I. A a
186 OBSERVATIONS ON THE
adult, it may, even in this more dilated state of it, be kept from
being very inconvenient.
If an inflammation comes on, the tumor is thereby considera-
bly increased, the discharge is larger, as well during sleep as upon
pressure; the skin covering it loses its natural whiteness and soft-
ness, becomes hard, and acquires an inflamed redness; and with
the mucus a mixture of something, which in colour resembles
matter, is discharged, especially if the pressure be made with any
force, or continued for any time: this circumstance, added to the
painful sensation, and inflamed appearance of the parts, has been
productive of a supposition, that in this there is either an ulcer
or an abscess within the sacculus or duct.
As this is an opinion which, though it may possibly sometimes
have some foundation in truth, yet it is in general entertained
much too hastily, and is also the principal source whence most of
the mistakes concerning this disease have sprung, I would beg
leave to be indulged a few words on this subject.
It has already been observed, that from the surface of the mem*
brane which lines these parts a thin mucus is secreted, by which
its surface is smeared over, in the same manner as is that of all
the membrane which covers or lines the fauces, larynx, and in-
ternal parts of the nose, the antra of the jaws, and the sinuses of
the sphenoid and ethmoid bones, &c. While the lachrymal sac
is free from disease, and the ductus ad nares open, this mucus is
nearly limpid in colour, small in quantity, and passes insensibly
into the nose with the fluid from the lachrymal gland; but when,
by the obstruction of the nasal duct, that passage is denied, it ne-
cessarily lodges in the sacculus; by distending and irritating its
containing bag it is increased in quantity, altered in colour, and
discharged at the puncta lachrymalia, as it either becomes too
much for the sac to contain, or as it is forced out by pressure.
This is a short and succinct account of the true nature of the dis-
ease, and such as will fairly and truly account for all its symp-
toms and appearances, without any recourse to either abscess or
ulcer, circumstances which very seldom, if ever, attend it.
That which is mixed with the clearer part of the mucus, and
which from its pale yellow hue is taken for matter, is not matter,
but mucus, which in this part, as well as several others in the
FISTULA LACHRYMALIS. 187
body, does, either by being confined beyoml the necessary time,
or by inflammation, or irritation of the gland or membrane which
secretes or contains it, or even from general affection of the habit,
put on a yellow purulent colour, where there is neither abscess
nor ulcer in the part whence it comes.
So many instances of this are producible as to put the matter
beyond all doubt; the urethra, vagina, and all the sinuses of the
head which communicate with the nose, furnish us with them
daily; the linings of all these are constantly imbued with a mu-
cus naturally clear, and no more in quantity than is necessary to
keep the membranes moist; but either inflammation or irritation
does immediately so add to its quantity, and so alter its colour,
that in the two former the same mistake has often been made as
in the subject in question; that is, the discharge has been thought
to be purulent, and produced by ulceration of the parts.
These two fluids, pus and mucus, which have been so frequent-
ly confounded together, do really differ so widely from each other
in their nature, constitution, sources, purposes, and effects, that to
distinguish them properly, and to point out the true character of
each, seems to be a matter of much importance: it would carry
me too wide from my present purpose to attempt it in this place,
and therefore I shall only just mention what may serve merely to
illustrate that.
If I conceive rightly of this affair, mucus, considered in a gene-
ral sense, is the jfffect of a natural secretion made by glands,
membranes, or other bodies appointed for that purpose, and is so
far from being originally the consequence of disease, that, in a
due quantity, it is absolutely necessary for several very important
purposes in the animal economy; which purposes, when this fluid
is deficient, must be ill executed, and some kind of disease or de-
fect follow: whoever will reflect upon the uses of it in the intes-
tines, joints, sheaths, or capsulae of the tendons, in the sinuses of
the sculi serving the purposes of speech, in the cavity of the nose,
where the olfactory nerves do their duty, in the prostate gland,
larynx, trachea, urethra, and vagina, will be easily convinced of
the truth of this assertion, both with regard to its natural uses in
a healthy state and proper quantity, and the share it frequently
188 OBSERVATIONS ON THE
has in the production of diseases, when it is either vitiated or re-
dundant.
' Pus, or matti-r, is certainly no natural secretion; suppuration,
though it be an act of nature when some paris of the body have
been forcibly divided from each other, is nevertheless to be re-
garded as the effect of violence and destruction, at least of divi-
sion; for, without entering minutely into the origin or nature of it,
I believe I may venture to affirm, that the dissolution of some of
the solid particles of broken capillary vessels, and a mixture of
some part of the juices which should circulate through them,
make a necessary part of its production. However constant its
appearance may be in the progress toward healing a wound or
sore, yet it never is produced, even in the smallest quantity, with-
out some degree of erosion, some breach in the natural structure
of the parts; and when such breach is healed, the discharge ne-
cessarily ceases.
On the contrary, mucus may, by irritation, relaxation, or de-
fluxion, on its secreting or containing parts or organs, be increas-
ed to a quantity far beyond what is necessary or useful, and pro-
duce thereby a disease in parts where there is not the least
degree of solution of continuity, as in the cases of tenesmus, stone
in the bladder, fluor albus, and simple gleets from the urethra; as
also in that kind of deOuxion on the nose and fauces, producing a
catarrh, and in the immediate effect of all sternutatories.
Other differences between the nature and pi^perties of the two
fluids might be mentioned; but if these already cited are just, they
will be sufficient to evince the impropriety of confounding them
together, either with regard to theory or practice.
Nor is this mistake of discoloured mucus for matter confined to
the lachrymal sac only; the two circumstances of pain, and yellow
colour, having in almost all times produced the same misconcep-
tion in the virulent gonorrhoea of both sexes : this has been called
pus, and being said to proceed from ulcerations in the urethra and
vagina, though the repeated- testimony of those who have, imme-
diately after death, examined the parts of persons so diseased, has
often been produced to the contrary, and though the discharge itself
•when properly examined will always prove the contrary, inflam-
mation and irritation of the membranous linings of the urethra
FISTULA LACHRYMALIS. 189
and vagina will fully account for all the appearances in this disease,
in which there is neither matter, nor ulcer, nor abscess: whoever
will attend to the discharge made from a purulent ulcer, will find
it widely different from that which issues from either of the above
parts in the gonorrhoea.
Again, in case of strictures in the male urethra, the discharge
occasioned by a bougie, properly and judiciously used, is a disco-
loured mucus, and not matter, though it is generally so called: it
is* from the discharge of this mucus, and the dilatation of the pass-
age, that the relief is obtained, not from any destruction or divi-
sion of parts: the bougie which produces true matter does much
mope harm than good, and makes a sore where there was none,
and where there ought to be none. How often do catarrhous de-
fluxions on the trachea and larynx wear toward the close a deep
purulent colour, so as to deceive the unknowing into an opinion,
that it is matter upon the lungs? But no judge of these things ever
had recourse to abscesses, or ulcers for a solution of such appear-
ance. The argument drawn from the quantity of these discharges
is as erroneous as those taken from its colour; as an inflammatory
defluxion on the part does generally occasion the latter, so mere
irritation will produce the former, which does also generally cease
when the irritating cause is removed or appeased. How imme-
diately is a most troublesome totnesmus cured by a clyster of starch
and opium .f* What large foetid discharges are made from behind
the prepuce of many persons, not only free from all venereal taint,
but without any ulceration of the parts, by a kind of exsudation?
To what length of time will they not continue, if neglected, and
how immediately do they cease by the use of a spirituous or
vitriolic wash? How often is the fiuor albus, even in some of its
worst circumstances, moderated, not to say cured, merely by wash-
ing away the acrid mucus, which, lodging in the rug® of the
vagina, continually irritated the parts to a fresh discharge, and
perpetuated the disease? What quantity of slime is there in the
urine.of those who have a stone in the bladder? And how totally
does it cease, upon that stone being discharged, or iaken away?
Whereas neither cleansing of parts, nor removal of irritating
bodies, does, or ever can procure, an immediate cessalioa of a dis-
charge of true matter, which being occasioned by a solution of con-
190 OBSERVATIONS ON THE
tinuity, an erosion or division of the parts whence it proceeds
must decrease gradually, and at last can only cease by such part
becoming whole again.
In short, the two fluids are so absolutely diflerent and distinct,
that the blending them together in our ideas of disease, proceed-
ing from, or producing either of ihem, cannot be too industriously
avoided. It is a subject on which a great deal more might be
said, as it would comprehend, or have relation to many disorders
which perhaps are not sufficiently understood, or attended to; but
being beside my present purpose, I shall say no more about it, only
desire that I may not be misunderstood as if I meant to assert,
that there never is abscess or ulcer in the lachrymal sac and duct:
No, I only mean to signify, that it is my opinion, that the yellow
or purulent colour of the discharge, which is generally received as
a proof of such, is no proof at all; that this colour may be, and
most frequently is, dependent on other causes; that though by the
suppuration of the cellular membrane covering the sac, the upper
part of it sometimes becomes sloughy, and bursts; yet the lower
part of it, and the nasal duct, are often at the same time perfectly
sound; and that there never is abscess or ulcer within, while the
skin is entire, and preserves its natural hue and softness, let the
colour of the discharge be ever so yellow; circumstances of no
small consequence in the treatment of this disease,,
The inflammation of the cellular membrane covering the sac,
is a circumstance which makes a considerable diflerence, both in
the appearance of the disease, and in its requisite treatment: in
some cases it is confined merely to the surface of the tumor in the
corner of the eye; in others, it spreads still farther, affecting the
eye-lids, cheek, and side of the nose.
When the parts are in this state, the mucus within the bag has
generally the appearance of being matter, that is, it wears a deep
yellow colour, and is of a more thin consistence. If the puncta
lachrymalia are naturally large and open, and the inflammation
confined to the surface of the sac, its contents will pass off pretty
freely, and the skin will remain entire:' this is what the ancients
called the simple, or imperfect, or anchylops.
But when the skin covering the lachrymal bag has been for
some time inflamedj or subject to frequently returning infiamma-
FISTULA LACHRYMALIS. 191
tions, it most commonly happens, that the puncta lachrymalia are
affected by it, and the fluid, not having an opportunity of passing
off through them, distends the inflamed skin, so that at last it be-
comes sloughy, and bursts externally. This is that state of the
disease which is called perfect Aigylops, or iEgylops; the dis-
charge which used to be made through the puncta lachrymalia,
while the skin was entire, is now made through the new opening,
and, by excoriating the eye-lids and cheek, increases the inflam-
mation, and gives the disease a much more disagreeable appear-
ance. In some the matter bursts through a small hole, and, after
it has discharged itself, the tumor subsides, the neighbouring parts
become cool, and, though the skin covering the surface of the sac-
culus is sloughy and foul, yet there is no reason to believe that the
sac itself is much diseased below; in others the breach is large, the
skin remains hard and inflamed, and, from the appearance of the
sore, there is reason to suppose the whole inside of the bag to be in
a diseased state; and, in some cases, which have been much ne-
glected or irritated by ill treatment, the cavity of the sacculus
seems to be filled with a loose ill-natured fungus, which gleets
largely, and produces inflammation and excoriation of all the parts
about.
There is also another circumstance which sometimes is found
to attend this disorder, viz. a carious state of the bones. This was
by our forefathers supposed to be a frequent one, and was the prin-
cipal reason for their so free use of caustic, cautery, and scalpra,
in the treatment of it; but, since the disease has been more mi-
nutely examined into, this <;ircumstance has been found to be a
very rare one. When the fistula lachrymalis is a symptom of the
lues venerea, as it sometimes is, the bones are indeed often carious;
but then, the fistula is not the original complaint, but produced
secondarily, and is a consequence of the diseased state of the os
ethmoides, and ossa spongiosa, of the nose, and is not curable by
any local means or applications, but depends entirely on the cure
of the disease of which it is a symptom.
I have also seen an abscess after the small-pox, which, by falling
on the lachrymal bag, has made it all slough away, and leave the
bones bare; which circumstance I have also seen attend the free
use of stroiig escharotics applied to destroy what is called the cyst:
192 OBSERVATIONS ON THE
but, without the accession of some other disorder producing it, or
the most absurd method of treating the complaint, I believe that a
caries of the bones will very seldom be met with. Indeed the
combination of other diseases, either of the general habit, or af-
fecting the same, or the neighbouring parts, does often make a very
material difference, both in the appearance of the disorder, in the
prognostic, and in the proper method of treating it, which, there-
fore, should always be inquired into: for instance, the patient is
sometimes subject to an habitual opbthalmy, or lippitudo,, which
will add to the deformity, and give a good deal of adiliiional trou-
ble during the cure; an ozajna, or some other disease of the mem-
brane, and cells of the ethmoid bone, or a polypose excrescence
within the nose, are now and then combined with it: the habit is
sometimes, as I have before observed, infected with the lues ve-
nerea, of which this disease may be a symptom; stiumous glandu-
lar obstructions are its too frequent companions; and, what is worst
of all, it is sometimes cancerous.
SECT. I.
From what has been said, I think it will appear that this dis-
ease, in its primary and most simple state, consists in a detentioa
or lodgement of mucus in the sacculus lachrymalis, in consequence
of an obstruction of the natural passage from that bag into the nose;
that by means of this lodgement the sacculus is distended, irritated,
and sometimes inflamed; that the fluid which passes from the la-
chrymal gland over the eye to the puncta lachrymaiia, being pre-
vented by the fulness of the sac from getting into it, runs down the
cheek; and therefore that the characteristic marks of the disorder^
when recent, are a small tumor in the corner of the eye, an invo-
luntary flux of serum down that side of the face, and a discharge
of mucus through the puncta lachrymaiia upon pressure.
This lodgement, being originally produced by the stoppage of
FISTULA LACHRYMALIS. 19S
the natural duct, it follows, that the first curative intention is, the
removal of that obstruction; which is sometimes practicable, but
more often not; the degree of obstruction, its dale, the state of
the adjacent parts, and some other circumstances, rendering it more
or less so in different subjects.
That the inexperienced practitioner may be guarded against
giving a hasty prognostic, or making attempts, which, however
fatiguing to the patient, must in the end prove fruitless; and that
he may be enabled to understand the disease more perfectly, I
shall take the liberty to divide it into four general heads, or states,
under which all its lesser distinctions may be comprehended.
The first consists in a simple dilatation of the saccuius, and
obstruction of the nasal duct, discharging upon pressure a mucus
either quite clear or a little cloudy; the skin covering the bag
being entire and perfectly free from inflammation.
In the second, the tumor is somewhat larger; the skin which
covers it is in an inflamed state, but entire; and the discharge
made through the puncta lachrymalia is of a pale yellow, or puru-
lent colour.
In the third, the skin covering the saccuius is become sloughy
and burst, by which means the swelling is in some measure less-
ened; but the mucus, which, while the skin was entire, used to
be pressed out through the puncta lachrymalia, now discharges
itself through the new aperture; the due tus ad nares, both in this
and the preceding state, is not otherwise diseased, than by the
thickening of its lining.
In the fourth, the passage from the saccuius lachrymalis in
the nose is totally obliterated, the inside of the former being either
ulcerated, or filled up with a fungus, and attended sometimes with
a caries of the bone underneath.
These will, I think, comprehend every state and circumstance
ef the disease, and, if attended to, will in general point out the
proper method of treating it.
The ancients, who supposed this disorder in its first state to be
an inflammatory defluxion from the brain on the caruncle tending
to suppurate, directed their first attention to prevent such conse-
quence; for vphich purpose they employed phlebotomy, cathartics,
VOL. I. B b
194 OBSERVATIONS ON THE
issues, setons, collyria, and refrigerant applications of all sorts;*^
and these not succeeding, they had recourse to such as they thought
would hasten the suppuration of the supposed abscess.^
<=The old writers have many forms of collyria, epithems, &c. which they
used upon this occasion, but issues and setons they lay great stress on, which
practice may immediately satisfy us what was their opinion of the nature of
the disease.
" Omnium vero praestantissimum est setaceum, materiam enim ad oculos
" fluentem potenter ad se trahit et evacuat, caput ab omnibus excremen-
" titiis humoribus expurgat, et egregie coroborat; quid plura, tanti est
" momenti ut inveleratam fistulam lachrymalem sine hoc prsesidio vix curari
" posse."
Mr. Serjeant Wiseman most certainly did not understand this disease;
and mistook it either for a tumor of the encysted kind, or for an inflam-
matory defluxion, and treated it as such: his words are —
" -Eirylops is a tumor of the inner canthus of the eye, either scrophulous,
" xtheromatous, or of the nature of a meliceris, or sometimes with inflamma-
"tion: the causes of ^gylops are the same that produce the like tumor in
" other places, but sometimes it is made by fluxion, and appeareth first as a
" phlegmon: if it be struma or atheroma, it is made by congestion."
" The indications of cure are taken from the JEgylops, whether it be in its
" beginning with inflammation, or by congestion, passing its matter forth
*' under the cllium' into the e3^e, in which case it is fistulated. Anchylops
" has also its peculiar way of treating, as other tumors of the glands."
Without any design to criticise on the strange unintelligibility of the
Serjeant's language, I believe I may venture to say, that no man who is not
previously acquainted with the nature of the disease, will learn from hence
that its seat is in the lachrymal sac, and that an obstruction in the nasal duct
is the first cause of it.
To come still nearer, or even into our own time, Dr. Daniel Turner com-
piled a treatise of surgery, which was universally dispersed and read all over
the kingdom, and was at that time generally looked upon as a true represen-
tation of the London practice: the Doctor says, •' Anchylops or -Eg3dops are
" diseases of the internal canthus of the eye, in which the lachrymal gland is
" concerned, and from whence the fistula of the same part is denominated:
" the prognostic may be gathered from the method of cure, in which uni-
" versals premised, such as bleedings, purgings, &,c. you may attempt to
" dissolve the humour by some gentle anodyne, or discutient cataplasm; but if
" it inflame and suppurate, you must hasten maturation, as well as the dis-
" charge, by reason of the part it lies upon j but when, notwithstanding ali
" your endeavours to incarn and agglutinate, the matter continues to dis-
" charge itself, not only by the outward orifice, but also under the cilium
" into the eye, you must try some more powerful desiccative."
I believe no one will venture to say, that the nature and seat of the
disease are more or better explained by what the Doctor has said, than by the
FISTULA LACHRYMALI3. 195
By the improper use of medicines of the latter kind, it fre-
quently happened that the skin became inflamed and bruised; the
discharge which necessarily followed this accident, together with
the heated appearance of the parts about, confirmed tbtir opinion
of a collection of matter within; and according to such supposi-
tion, they attempted to obtain a cure by dilating the orifice, and
endeavouring to make an incarnation from the bottom of the
hollow: not being acquainted with the situation or use of the
nasal duct, they took no care to free it from the obstruction under
which it laboured, but dressing the sore like a common impos-
thumation, permitted it either to be filled up with a loose fungus,
or to contract itself to a narrow fistulous orifice, which daily
discharging a discoloured kind of fluid, and not healing by such
means as they made use of, they concluded the bone underneath
was carious, and made way down to it, either by removing the
parts with a cutting instrument, or by destroying them with caustic
and cautery, intending to procure an exfoliation, and thereby a
firmer basis to heal on.s
But since the use of the ductus nasalis has been known, since
it has been discovered that an obstruction in this is the primary
and principal cause of the disorder, and that what passed for the
cavity of an abscess is really the sacculus lachrymalis, both the
intention of cure and the means have been considerably altered.
Serjeant j and I think it is perfectly clear thkt neither of them hnd any true
idea of it at all: they botli mistook the caruncle fov the lachrymal gland, and
the disease for an encysted, or a scrophulous tumor, which ought to be
brought to suppuration ; the lachrymal sac, the ductus ad nares, their use,
and the disorder of them creating the complaint in question, they were totally
unacquainted with.
8 Humulo summum ejus foraminis excipiendum, et totum id cavum sicut
in fistulis dixi, usque ad os excidendum.
Celscs,
Corpus id quod inter angulum usque ad abscessum est excoluimus, et
carnes e profundo educimus ; quod si igitur per summa ruptus fuerit ab-
scessus, totum id quod eminet usque ad os excidendum.
PAt'itrs.
Si vero perhaec medicamenta non curetur, aut recediraret poslea, signum
est quod OS est corruptum de subtus, quare tunc oportet locum detegl et os,
corruptum removeri.
196 OBSERVATIONS ON THE
In the first and most simple state of the disease, viz. that of
mere obstruction without inflammation, much pains have been
taken to restore the parts to their natural state and use, without
making any wound or division at all; the introduction of a probe,
the injection of a fluid, and a constant compression made on the
outside of the sacculus in the corner of the eye, are the principal
means by which this has been attempted.
Some [ew years ago M. Anel made a probe of so small a size
as h> be pable of passing from the eye-lid into the nose, being
introduced at one of the puncta lachrymalia, and passing through
the sacculus and duct; with which probe he proposed to break
through any small obstruction which might be found in its pass-
age.
He also invented a syringe whose pipe is small enough to en-
ter one of the puncta, and by that means to furnish an opportunity
of injecting a liquor into the sacculus and duct; and with these
two instruments he pretended to be able to cure the disease
whenever it consisted in obstruction merely, and the discharge
was not much discoloured. The first of these, viz. the passage
of a small probe through the puncta, has a plausible appearance,
but will, upon trial, be found very unequal to the task assigned:
the very small size of it, its necessary flexibility, and the very
little resistance it is capable of making, are manifest deficiencies
in the instrument; the quick sensation in the lining of the sac and
duct, and its diseased state, are great objections on the side of
the parts, supposing that it was capable of answering any valua-
ble end, which it most certainly is not.
That the passing a fine probe from one of the puncta lachry-
malia into the nose is very practicable, I know from experience;
but I also know from the same experience, that the pain it gives,
and the inflammation it often excites, are much greater than any
benefit which does or can arise from it.
It is said that the principal use of this probe is to clear the lit-
tle ducts leading from the puncta into the sacculus, and the ob-
struciion of those ducts is often mentioned as a part of this
disease; by which one would be led to suppose that it was a cir-
cumstance which frequently occurred, whereas it is seldom or
uever met with, and when it does happen, can never produce the
FISTULA LACHRYMALIS. 19*^
disease in question, the principle characteristic of which is, a dis-
charge into the inner corner of the eye upon pressure made in the
angle: this discharge is made from the sacculus, through the punc-
ta, and proves that the latter are open. The passing a probe there-
fore through these seems to be perfectly unnecessary, since a
stoppage of them would never give rise to that disease, which con-
sists in an obstruction to the passage of any thing from the sac
into the nose, and not from the eye into the sac.
The syringe, if used judiciously while the disease is recent, the
sac very little dilated, and the mucus perfectly clear, will some-
times be found serviceable: I have used it where, I think, it has
been much so; I have by means of it injected a fluid through the
sacculus into the nose, and in two or three instances have effected
cures by it: but I have also often used it ineffectually; it gives no
pain, and a few trials render the use of it very little troublesome.
Fabritius ab Aquapendente invented an instrument, which was
so contrived, as by means of a screw to make a pressure exter-
nally on the lachrymal bag, from the use of which, he says, his
patients received much benefit: this instrument has been consider-
ably improved by late practitioners, and is still recommended as
very useful.
All the good that can be obtained by compress and bandage,
this screw is capable of procuring; but it is also subject to all the
same inconveniencies, arising from the impossibility of determin-
ing exactly the due degree of pressure: for if it be so great as to
bring the sides of the upper part of the sac into contact, all com-
munication between it and the puncta will be thereby siopt: if it.
be but slight, the accumulation will not be prevented, nor does it
in either case contribute to the removal of the obstruction in the
nasal duct, the primary and original cause of the disease.
If the curative intention was to procure an union of the sides
of the sacculus, as in the case of parts separated from each other
by the formation of matter or sloughs, and the pressure could be
made uniformly and constantly, possibly it might be so managed
as to answer a valuable purpose: bui as that is not the intention,
the pressure, whether made by an instrument, or by a common
roller and compress, contributes little or nothing toward a cure,
198 OBSERVATIONS ON THE
nor did I ever see one effected by it, although I have several
times tried both.
That some slight obstructions of the nasal duct have gone off
while the compression has been used, I do not deny; but am in
great doubt concerning the share which it had in removing them,
having seen more than one instance of a cure being obtained by
the use of a proper regimen and medicines, in slight and recent
cases, where nothing is used externally but a vitriolic collyriom;
and having been always disappointed in my attempts at mere
bandage of any kind.
Besides these means of attempting a cure without incision, the
gentlemen of the French Academy have favoured us with some
others, such as the introduction of a probe into the lower part o^
the nasal duct within the nose, the injection of a fluid by the same
orifice, the passing a seton from the punctum lachrymale superius
through the sacculus and duct, and out at the nostril, there to re-
main till the cure is completed; and for those purposes they have
invented and given figures of a number of probes, syringes, and
many other instruments, which, they say^ have been very success-
fully used: far be it from me to say that they have not, or to pre-
vent any body from trying those, or any other means by which
mankind may be cured of diseases with the least possible fatigue
and pain; but from the experiments which I have made of most
of these processes, I must beg leave to suspend my assent to their
general utility, or even to their frequent practicability.
Repeated trials upon dead subjects will undoubtedly enable a
-man to pass the probe, or perhaps now and then the seton, but he
xvill also find it often absolutely impracticable; and in the few in-
stances in which he may chance to succeed as to this attempt,
what will in general be the consequence? not what the writers on
these subjects have taught him to believe, a cure, but a sense of
pain and degree of inflammation, which the patient, before such
attempts were made, was free from — an exasperation of the dis-
ease, and a loss of much time, as I have more than once experi-
enced. To which consideration may be added, that infanls and
young children are very often afflicted with this disorder, and that
such processes as these are absolutely impracticable upon them.
I should be very sorry to be misunderstood in what I now say,
FISTULA LACHRYMALIS. 199
to have it suspected, that I mean to derogate from the character
of those gentlemen who have been the inventors of these opera-
tions, or that I speak slightingly of them, either because they are
not my own, or because I have not been able to succeed in the
use of them: it would give me great concern if I thought it would
be believed that I acted upon so mean, so narrow a principle; nO
man is or would be more pleased with any real improvement in
our art than myself; but having taken all the pains in my power
to apply the discoveries of which I am now speaking to practice,
(the only test of good surgery,) and having found them most fre-
quently impracticable, always ineffectual, I think myself obliged
to say so.
Anel's syringe I have used successfully, and think it may now
and then be very well worth trying, in recent cases more espe-
cially, as it may always be used without giving any pain or run-
ning the risk of raising an inflammation; but I must also beg
leave to observe, that if the bag is not much dilated, the mucus
clear, the skin and cellular membrane uninflamed, and the parts
about soft and easy, if the patient will take care not to suifer too
great an accumulation, will, by the frequent use of a vitriolic col-
lyrium, keep the eye-lids clean and cool, and carefully avoid such
things as irritate the membrana narium, or occasion a sudden
flux of lymph from the lachrymal gland, the disease may for many
years, nay often for life, be kept from being very troublesome or
inconvenient, without any surgery at all.
SECT. V.
When the disease is got beyond the simple state just described,
that is, when the parts round about are much, or constantly in-
flamed, or the skin covering the tumor is burst, there is something
more to be done if a cure be intended.
In this state an opening in the upper part of the sacculus lachry-
malis becomes in general absolutely necessary; and as a wound
made by a knife leaves a much less disagreeable scar, than that
which necessarily follows the bursting of the skin, one being a
200 OBSERVATIONS ON THE
Caere simple division, the other a loss of substance, it will always
be found best to anticipate the accident of bursting, by making
the opening as soon as the integuments are in such a state as to
threaten it/
For the making this incision authors have been very particular
in their direction with regard to its place, manner, and form: they
have ordered it to be semilunar, having its concave part toward
the eye, and that the point of union of the lids should be exactly
opposite to the centre of the incision. This lunated figure was
calculated to correspond with the course of the fibres of the orbi-
cular muscle, upon a supposition that a transverse section of them
would produce an inversion of the lower lid, an effect which never
follows. All that the surgeon need observe is, to take care to
keep the knife at a proper distance from the juncture of the pal-
pebree, to begin the incision a very little above a line drawn from
that juncture toward the nose, and to continue it downward: its
form may full as well be straight as any other, and the best in-
strument to make it with is a small crooked bistoury.
If the sacculus is already burst, the place of opening is deter-
mined, and the orifice may be enlarged with a knife, or di-
lated.
The incision made, the sacculus should be moderately distend-
ed, either with dry lint, or a bit of prepared sponge; by which
means an opportunity will be gained in two or three days of
knowing the state of the inside of the sac, and of the ductus na-
salis: if the former is neither sloughy nor otherwise diseased, and
the obstruction in the latter but slight, it sometimes happens, that
after a free discharge has been made for some days, and the in-
flammation occasioned by the first operation is gone off, the sac
f I cannot but be of opinion, that in this case, and many othei* abscesses, the
opening which nature makes from witliin generally heals with less scar or
mark than that which is made by a cutting instrument. It is certainly in
many cases wrong to let matter remain after it is palpably formed; as in
some situations it is capable of doing injury to the parts on which it is situat-
ed. I only mean to say, that when matter may be safely left till it makes its
own way out, the scar is not so visible as when an opening is artificially
made; as, except in those cases where from violent inflammation and disten-
sion a sphacelus is induced, the natural opening is rather a distraction.than
a destruction of fibres, or loss of substance. E.
FISTULA LACHRYMALIS. 201
contracts itself, a superficial dressing, with moderate pressure,
heals the sore, the lachrymal fluid resumes its wonted course,
and the disease disappears.
Of this I have seen more than one instance, and perhaps it
would happen oftener, if the very absurd manner in which this
disorder is generally treated after opening the bag, did not pre-
vent it: in this state success is to be expected from the most gen-
tle treatment only: whatever irritates, inliames, or destroys, will
infallibly prevent it.
If this simple method does not succeed, or from the state of the
parts seems unlikely to do so, another must be tried, which the
opening already madfewill enable us to put in practice: the point
to be aimed at is, if possible, to render the nasal duct pervious to
the lachrymal fluid; and we must endeavour to obtain this end by
such means as give the least pain, excite the least inflammation,
and leave the parts as near as possible in their natural state; that
is, we are to endeavour to dilate the passage from the sac to the
nose, by some means which will gradually distend it without de-
stroying its texture, in the same manner as the dilation of the ure-
thra ought to be effected in the case of strictures, by passing either
a probe, or a piece of cat-gut, or a bougie, gently into it, as far
as it will easily go, and repeating it occasionally until it is got
quite through and the passage is free.^^
Every man will determine for himself, by what means he will
endeavour to accomplish this end; nor is it of very material con-
sequence which he prefers, provided it be done gradually, and
without giving pain: a proper dilatation of the upper part of the
sacculus by dry lint, or a bit of prepared sponge, will be found
useful previous to the attempt toward passing any thing into, or
through the duct; and it will also be necessary that the surgeon
be possessed of a just idea of the size and direction of it, both in
a natural and a diseased state; for whoever has formed one only,
E This caution is very necessary to be observed in the cure of strictures of
tlie urethra, in which case the proper intention is gnulually to dilate the pass-
age, and to procure an increased discharge of mucus from the lacuna:; this
should always be done gently, and by means which give as little pain as possi-
ble; whatever irritates or gives pain will certainly do miscliief. will add to
the obstruction! and increase the dysury.
VOL. I. C C
202 OBSERVATIONS ON THE
from viewing its bony channel in a dry scull, will upon experi-
ment find himself much deceived with regard to its diameter in a
living subject; the membrane which lines it is not extremely thin,
in a healthy state, and when it is inflamed or thickened by ob-
struction, the passage through the duct is thereby rendered very
small, if it is not quite shut up.
They of our ancestors who mistook this disease for an abscess,
and found (as indeed they always must) extreme difficulty in filling
it up with sound flesh, generally had recourse to escharotic medi-
cines for the destruction of that fungus which seemed to hinder
them from accomplishing their end; by which conduct they irri-
tated all the neighbouring parts, increased the inflammation, and
were most frequently frustrated in their expectation of a cure at
l?ist. The same kind of medicines were also used by those who
supposed the disorder to be an encysted tumor, with intention to
eradicate the cyst, which, they thought, prevented a cure by re-
maining behind; 9nd both these methods of practice were vindi-
cable, supposing their idea of the disease had been a true one,
which it most undoubtedly was not: their reasoning was right, but
their principles were wrong; they were in general very little ac-
quainted with the structure and use of the parts, and totally mis-
took the nature of the disease.
But now, that we are thoroughly acquainted with both, this kind
of practice ought surely to cease, as the preservation of the sac-
culus and duct, and not their destruction, are, or ought to be in-
tended: ail cathasretic medicines must be wrong and prejudicial,
at least while the intention is such; an intention at all times
rational, and sometimes capable of being fulfilled.
Notwithstanding the destruction of the bag is allowed to be
lyrong by most surgeons of the present tiaie, yet there are many,
who, by their manner of dressing it, after they have opened it, do
really, thought not intentionally, produce the same effect as our
forefathers aimed at: it is still a custom with many, as soon as it
is opened, to distend the cavity of it with a hard tent, or with dos-
sils of lint charged with escharotic medicines, such as mercurius
precipitatus ruber, &c. by which means the inflammation is in-
creased, the skin and edges of the incision hardened, and the
inside of the sacculus put under the necessity of casting off a
FIStliLA LACHRYMALIS. 20^
slough. This is one of several instances still remaining of our ad-
hering to old methods of practice, after the principles, on which
such methods were originally formed, have been allowed even by
ourselves to be erroneous; for this manner of dressing the sore is
effectively the same as the ancients made use of, while they sup-
posed the disease to be an abscess of the caruncle, and encysted
tumor, or a callous ulcer with carious bone; and was by them in-
tended very properly for the destruction of such callosity, to assist
the exfoliation of the supposed caries, and to procure a firm basis
to incarh upon.
On the contrary, the point which ought first to be aimed at, im-
mediately after having made an opening into the sac, is to endea-
vour to remove' the obstruction of the natural passage from thence
into the nose, by the means already mentioned, which design this
method of cramming in escharotic dressings must necessarily frus-
trate, must frequently render a simple case complex, and at least
retard that cure it is designed to expedite.
The only excuse that can be now made for such method of
dressing is, that the surgeon is satisfied that the ductus ad nares
cannot be restored to its use, and therefore, by destroying part of
the sacculus, intends to procure such a generation of new flesh, as
may fill up its cavity, and hinder the accumulation or lodgement
there in future.
If this was feasible, perhaps it might be a vindication of such
treatment; but unfortunately it neither is, nor can be so in gene-
ral; and whoever will attentively examine the natural situation
and structure of the parts concerned, will immediately see why it
cannot. All, or the greatest part of the diseased and obstructed
duct, lying in its bony channel out of the reach of what is applied
to the inside of the sacculus, must prevent the generation of a firm
basis at its bottom, and produce a fresh collection of mucus, which
in a short space of time lifts up the cicatrix into a new tumor, and
requires the same treatment as if nothing at all had been done.
On the other hand, it must not be denied, that now and then a
cure has by this means been effected; but it has been so rarely,
that it can hardly be admitted as an authority or vindication of so
irrational an attempt.
The parts about the eye are most of them of very quick sensa-
204 OBSERVATIONS ON THE
tion, and easily irritated; all dressings are in fact extraneous
bodies, and therefore, when applied to such parts, cannot be too
soft and light: suppuration is an act of nature, not of art; and is
always best executed when she is least disturbed: this is a general
truth, and will hold good in all parts of the body, even where
suppuration may be most wanted: but in the present case, in
Tvbich the lower part of the sac, and all the duct, are often in such
state as not to require any suppuration at all, escharotic dress-
ings of any kind, by producing inflammation both of the eye and
caruncle, by rendering the edges of the sore hard or sloughy,
and by destroying the communication between the puncta lach-
rymalia and sacculus, must necessarily counteract the only proper
intention of cure.
1 would not in this place be thought to mean, that a mere
superficial pledget is all the dressing that is required: no; a mode-
rate dilatation of the upper part of the sacculus is at first abso-
lutely necessary, in order to get easily at the duct below; but this
should be effected without the use of corrosive applications of any
kind, and is best accomplished by prepared sponge, which will
distend to almost any degree wiihout destroying.
When a passage has been once obtained, it should be care-
fully kept open, either by apiece of cat-gut, a small bougie, a
leaden probe, or something of that sort; and when it is thoroughly
established, the sore may be permitted to contract, until it becomes
no more tlwn what serves for the introduction of the bougie into
duct; in this state I would advise, that it be kept open for some time,
injecting now and then a little aqua calcis, softened with mell.
rosar. through from above into the nose; and when it appears that
the passage is so free, and so well established, that there is good
probability of its preserving itself, the orifice in the angle of the
eye, by being covered only by a superficial bit of plaster, or pledget,
will contract and close; and if, during its closing, moderate pres-
sure be used on the sacculus, to prevent a fresh accumulation of
mucus, it will assist the cure.
Whether the sacculus, in a healthy and undilated state, is endued
with any degree of contractile power, which it loses by being
distended, or to what other cause it may be owing, I know not; but
I have more than once beeen foiled in my attempts towards this
FISTULA LACHRYMALIS. 205
method of curing the disease, by a fresh collection of mucus,
notwithstanding the nasal duct has remained open, as appeared by
the discharge made into the nose upon pressure on the tumor, the
immediate subsidence of the said tumor, and the passage of an
injection, or small probe, after having again opened the sac. Some
of these have, upon being again healed, remained good cures, and
others not; the uncertainty which attends these cases is great, and
the event never to be know^n but by experiment. Whoever says
that none of ihem are to be cured by the foregoing method, errs
as much as he would who should expect it to succeed in all.
Where the disease is in such state as to admit its being tried, it is
very well Tvorth while, as it is not painful nor tedious; and where
it does not answer our expectations, it is no hinderance to any
other more efficacious one being made use of afterward: in all
these cases, different circumstances in the patient, or in the state
of the diseased parts, must produce a variation in the necessary
treatment, both in general and particular: a bad habit w-ill require
the use of internal remedies; the combination of other diseases of
the neighbouring parts will add to the difficulty and trouble; and
even the fairest, and such as seem most likely to succeed, do some-
times resist this, and indeed every other attempt.
From the necessity of keeping the eye bound while dressings
are applied for the dilatation of the sacculus, an inflammation is
frequently raised. This, added to the necessary discharge of
serum, mucus, &c. is apt to heat and excoriate the parts about;
therefore, warm fomentations, cooling collyria, epulotic cerates,
and renewing the dressings as often as shall be necessary, with
whatever else can contribute towards keeping the skin clean and
cool, must be found serviceable as well as pleasant, and should
never be neglected .
206 OBSERVATIONS ON THE
SECT. IV.
The last state which I mentioned of this disorder is that in
which the natural passage from the sacculus to the nose is so
diseased as to be quite obliterated, or in which the bones are
sometimes found to be carious.
The methods hitherto described, have all been calculated to pre-
serve the natural passage, and to derive the lachrymal fluid again
through it: in this attempt they are sometimes successful; but
when they are not, there is no chirurgical means left, but to at-
tempt the formation of an artificial one in its stead.
The upper and hinder part of the sacculus lachrymalis is firmly
attached to the os unguis, a small and very thin bone just within
the orbit of the eye; which bone is so situated, that if it be by any
means broken through, or removed, the two cavities of the nose
and of the orbit communicate with each other, consequently the
OS unguis forms the partition between the hinder part of the lach-
pymal bag, and the upper part of the cavity of the nose; and it is
by making a breach in this partition that we attempt the forma-
tion of an artificial pr.ssage for the lachrymal fluid.
This operation, if considered merely as a perforation, is no in-
vention of the moderns; the ancients undoubtedly performed it:
but though it was executed much in the same manner as it is now^
yet it was not done with the same intention.
From the accounts which our ancestors have left us of the dis-
ease in question, it is plain, that they supposed it to be always at-
tended with a degree of callosity, and often with caries, and that
the surest way to obtain a cure was to lay the bone bare: this
they effected either by caustic or cautery, according to the hu-
mour of the surgeon, or the fears of the patient. If caustic appli-
cations vv'ere used, they waited the separation of the eschar; and
if they found, or believed the bone to be altered, they applied an
actual cautery to it: if the bone to which the iron was applied
was the os unguis, it was too thin to bear much heat, or much
pressure, consequently was easily burnt, or broke through, and
by that means an opening was made into the nose; a terebra was
FISTULA LACHRyMAUS. 207
Stiso sometimes made use of instead of cautery, and the same ef-
fect produced thereby.'*
By each of these methods, a passage being made from the sac-
culus lachrymalis into the nose, a cure was sometimes accident-
ally obtained; but the cautery was applied, either to destroy the
supposed callosity, or to desquamate a caries; and the terebra,
either for the same reason, or to make a passage for the discharge
of matter, which lodged, and as they thought hindered the heal-
ing of the sore; for as they were not acquainted with the natural
passage of the lachrymal fluid, it would be absurd to suppose, that
by means of this perforation they intended .the formation of an
artificial one. Callosity and caries were their two characteris-
tics of the disease; the dissolution of one, and the exfoliation of
the other, were all they had in view from the use of either caus-
tic or cautery, and the perforation of the os unguis was either
accidental, or made merely for the discharge of matter.'
Indeed, if we attentively consider what the old writers have
left us on this subject, it will appear, that though they knew that
i" Oculo et caeteris junctis partibus bene obtectis, os ferramento adurendum
est vehementius : quod si jam carie vexatum est, quo crassior huic squama
abscedat, quidam adurentia irnponunt. Celsus.
Cum islo pulvere in veritate fere mortificabam omnes fistulas curabiles, et
cum cauterio ferreo, aut aeneo — facia mortificatione tali totius carnis usque
ad OS, cum pulvere aut unguento superdictissuperpone mortificato but3'rum
et eschara aspice, et si fuerit os corruptum cauteriza ipsiim usque ad ejus
profundum. Gvl. dk Saliceto.
Postea si homo fuerit delicatus, per istud foramen mittatur Canelius ferreus
vel sneus subtilis usque ad profundum si poteris, et per ipsum canellum fer-
rum candens immitte et §stulce radices decoque : at si timuerit ign^m immita-
tur pillula de unguento ruptorio. Rolandus.
Osse detecto ferrum imprime calidum supra ipsum, et ipsum cauterium
niediocriter comprimendo, postea imple totum vulnus cum oleo rosarum
misto cum vitello ovi. Laxjeajtc.
•Fabritius ab Aquapendente, who in general copies Paulus, speaks of the
perforation as meant only to make a depending orifice for matter, " Post car-
" unculx et loci excisionem, terebra humorem aut pus in nares derivarint."
Fab. ab AaUAPENDESTE.
Gul. de Saliceto, and indeed many other of the ancient writers, speak of
using both cautery and terebra to the purpose of deriving the matter and sa^
nies which lodge in the sac, into the nose ; and, by making a depending ori-
tce, to procure a firm basis to heal on. " Aspice os, et si fuerit corruptum
*' cauteriza ipsum usque ad ejus profuuduip, et concavitatsm cum cauterio
208 OBSERVAXIONS ON THE
a passage into the nose was sometimes a consequence of their
use of the terebra and cautery, yet the operators had no very ac-
curate knowledge of the parts they made so free with; no precise
idea of the bone on which their instruments were applied, or
through which they passed; nor of the place most immediately
proper for such application of them: sometimes they perforated
the OS unguis very properly, sometimes the cautery or terebra was
thrust into the bony channel of the natural nasal duct, and some-
times they were applied to the nasal process of the maxillary su-
perior: the direction given by most of them to rasp the bone
(scalpris abradere) and to impress the cautery with some force,
that the bone may be sooner exfoliated, [ut citius squama absce-
dat,) plainly prove, that either they were not aware of the tender
structure of the os unguis, or that they did not intend to apply
their instruments to it: if the former was the case, the perfora-
tion was accidental; if the latter, they must have often done much
more harm than good; that is, they must have burned and de-
stroyed unnecessarily, parts which have little or nothing to do with
the disease; and by such treatment of them must have much of-
tener prevented than accomplished a cure>
The intention of the present practitioners in making this per-
" punctuali, et perfora ipsum ad aliam partem, ejus ut sanies per nasum fluat,
*' deinde incarnetur et consolidetur." Gul. de Salickto.
Indeed, the formation of an ai-tificial passage for the laclirymal fluid could
make no part of the intention of those who were not rightly acquainted with
the natural one.
Paulus mentions perforation with the terebra as the practice of some in
his time ; but from what he says, it is plain he did not practise it liimself,
or think it necessary, and that he regarded it only as a method of making a
depending orifice ; his words are, " Quod si jam carie vexalum est, ferro
candenti, acuto, ac in cuspidem abeunte adurimus spongia frigida madente
oculo imposita.
" Sunt qui post carunculse exclsionem terebra usi humorem aut pus in nares
«' derivarint ; nos autem satis habuimus eousque solum ferramentis ad ^Egy-
" lopem accommodatis adurere ut squama abscederet."
Paulus .SIgineta. — See also Fab. ab AauAPKjfniJSTE.
•t Petrus de Marchetti, though perfectly sensible that the os unguis was
often broken through by the cautery, yet insists upon it, that it served no
other purpose than to hasten exfoUation. " Prxterquam quod hujus perfora-
" tionis non alius sit usus quam ut os perforatum aut inustum citius abscedat.
" Observandum tamen non esse perforandum os nisi pr^sente maxima ipsius
nSTULA LACHRYMALIS. 209
foration is different from that of our ancestors; but it is more
National, and founded upon the nature and use of the parts con-
cerned in tlie disease: it is to form and maintain a new artificial
passage from the lachrymal bag into the nose, when the natural
one can no more be rendered useful, and without any view to any
thing else: this, I say, is the aim of them all; but though they are
perfectly agreed in their intention, yet they are not so with regard
to the instrument which they use, some still continuing the actual
cautery, others using other different instruments.
The ancients preferred the cautery, for reasons which have
already been assigned; but since the symptoms of callosity and
caries have been found to be very infrequent, and the os unguis has
been perforated solely with a view to make an artificial passage
into the nose, the cautery has with many lost much of its ancient
credit, and other instruments have been substituted in its place,
which give less pain at the time of using, and leave less deformity
afterward.
But though many have laid aside the hot iron, yet it still has
its advocates, who prefer it to every other instrument, and who
have therefore endeavoured to obviate its inconveniences: they
have directed that the cannula through which it passes be made of
a conical form, and so large at its lower end, as that they shall not
touch each other; they have ordered this cannula to be wrapped
round with wet rag, at the time of using it; they have placed a
check upon the top of the iron to prevent its point from going too
far, and have been particular in directing us to withdraw it as soon
as it is got through.
But notwithstanding these and every other caution, the cautery
gives great pain at the time of using; it lengthens the attendance,
and most commonly produces unnecessary deformity even in the
hands of the most dexterous; not to mention the horror occasioned
by thrusting a hot iron into the corner of the eye.
When the inconveniences arising from the use of this instru-
" corrupUone, sola siqu'irlem ejus superficie corrupta aut altera sat fuerit
**" partem laesam abradere." Petr. de Marchktti.
And Mr. Verduc, a very modern writer, is also of the same opinion, "Le
" mellleur remede pour amorter I'acide qui cause la carie, c'est de pass^p
" legerement un cautre actuel sur I'os sans le percer."
VOL. I. D d
210 OBSERVATIONS ON THE
ment, even in the best hands, are important, it may be easily guess-
ed what tlie) must be in those of the clumsy and ignorant; and
therefore, unless some real advantage attends it, it ought certainly
to be so discouraged, that no one may attempt to revive it. Let
us then see with what intent it has been used by those who have
appeared most fond of it, and who may fairly be supposed to have
best known how to manage it.
The defence made by the wet rag against the heat of the iron,
the disproportioned size, and the figure of the cannula, very plainly
show, that its effect is designed to be executed by the point only;
and the check at the upper end as clearly sliows, that that point is
designed to pass no farther than just through the bone, while all the
ill effects are occasioned by the upper part of the cautery on the
eye-lids and angle of the eye. Now, if it be not designed to pro-
duce any effect on any of the parts through which it passes down
to the bone, but merely to burn through that and the membrana
narium, and thereby make an opening into the nose, I do not see
how it differs from any other perforator of equal size, except in
the mischief it does to the parts above, which it should not affect.
It does indeed burn the bone and membrane, through which it
pierces, and thereby prevents the orifice from closing again imme-
diately; and this is certainly the principal end of perforation, by
whatever instrument it is performed; but it is also as certain, that
the same end is obtainable by means less mischievous and less
horrible.
Our ancestors had a very plausible reason for using it: their
ideas of callosity and caries always accompanied this disease, and
authorised them to make use of such applications as they thought
most proper in such cases: but now, when we know that these are
symptoms which very rarely occur, or even if they do, that they
are removeable in a much easier manner, we are no longer vindi-
cated in continuing an alarming and a painful process, when we
can obtain the same end by much gentler means; for whether the
membrana narium be burnt through, or divided in any other man-
ner, it is the future method of dressing that opening that must
maintain it, let it be made by whatever instrument, or in whatever
manner it may.
The late Mr. Chesselden was a warm patron of the cautery, took
FISTULA LACHRYMALIS. 211
a great deal of pains to prevent it from doing mischief, and has
said in its defence, that — " other methods of curing this disease
"have been much recommended, though often unsuccessful; but
"this, well performed, is infallible." After so positive an asser-
tion, I am sorrj to be obliged to say that it is contradicted by
manifold experience; that there have been many instances of per-
fect cures performed without the use of a cautery; and that some
of those who have been cauterised by Mr. Cheselden himself, have
been disappointed in the expectation of one: nor could he, with
all the pains he took, prevent the effect of the heat of the iron, or
leave his patient without a weeping eye.
The intention is merely to make an opening through the os
unguis and membrana narium into the cavity of the nose, and to
treat that perforation in such a manner as that it shall most pro-
bably remain open, and give passage to the lachrymal fluid from
the puncta, after the external sore is healed.
The extreme thinness of the bone renders the passage of the
instrument very easy, and if the breach which is made be of any
tolerable size, I am inclined to think that it never is filled up again
by bone; but that when it is closed, it is by the membrane; and
therefore it is the surgeon's business to make a pretty large open-
ing in the bone, and to prevent its being closed again, by render-
ing the edges of the membrane on each side of it callous.
To make this opening, many different instruments have been
devised and used; a large strong probe, an instrument like a com-
mon gimlet, a curved trocar, &c. &c. each of which, if dex-
terously and properly applied, will do the business very well; the
one necessary caution is, so to apply whatever instrument is used,
that it may pierce through that part of the bone which lies imme-
diately behind the sacculus lachrymalis, and not to push up too
far into the nose, for fear of injuring the os spongiosum behind,
while it breaks its way.
For my own part, I have always used the curved trocar, which
has served my purpose well, and from which I have never expe-
rienced any inconvenience: in using it the point should be turned
obliquely downward, from the angle of the eye toward the inside
of the nose; the accomplishment of the breach will be known by
the discharge of blood from the nostril, and of air from the woun-d
312 OBSERVATIONS ON THE
upon blowing the nose. The most precise direction in this part
of ihe operation will be of but little use to him who has no idea
of the natural structure and disposition of the parts concerned, and
who ought therefore to get such information as soon as he can:
but whoever is at all acquainted with this matter, or will attend
to the situation and connexion of the os unguis, knows that this
bone is divided into two parts by a perpendicular ridge; that the
lachrvmal sac is connected to all thai part which is anterior to
this ridge; and that the posterior part of the bone contributes to
form the orbit of the eye, and has little or no connexion with the
lachrymal sac: the trocar must be applied therefore to that part of
the bone which is anterior to the ridge, and consequently behind
the lachrymal bag. By the passage of the instrument, all this part
of the bone will in all probability be broken, but from which no
mischief will ensue.
An attention to the natural situation of these parts will also show
the practitioner, that if the point of his instrument be passed in a
transverse direction with regard to the nose, the os spongiosum
superius will be unnecessarily wounded or broken; and if it goes
in too perpendicular a direction, it may get into the channel of
the natural duct, and its point will be stopped by bearing against
that part of the maxilla superior which contributes to the forma-
tion of that channel.
It has been objected to the trocar, that it may break the os
unguis to some distance from the place where its immediate point
is fixed: to which I can only answer, that I have performed the
operation a great number of times, and never yet have seen any
inconvenience to arise from it: indeed, a total removal of a small
piece of the bone would be a thing rather to be wished for than
avoided. If we may reason by analogy, it seems to be a necessary
requisite toward preserving a future passage; for we very well
know, in a caries of the bones forming the roof of the mouth, that
they are sometimes bare for a large compass, and by casting off
leave a considerable aperture into the nose; yet in many cases,
when the virus is removed, and the habit recruited, that opening
will so contract as not to suffer a small quill to pass where you
might have introduced your finger, nay often will quite close;
and therefore, though the opening made in the os unguis may
FISTULA LACHRYMALIS. 213
possibly in spite of all endeavours be again closed up, yet a free
breach in it seems lo be the most likely means to prevent it; and
upon this principle I have always turned the perforator round
very freely whenever I have used it; have never seen any mis-t
chief from it; and do attribute the success I have had with it, ia
some measure, to this method of using it.
As soon as the perforation is made, a tent of lint should be
introduced, of such size as to fill the aperture, and so long as to
pass through it into the cavity of the nose: this should be permit-
ted to remain in two, three, or four days, till the suppuration of
the parts renders its extraction easy; and after that a fresh one
should be passed every day, until the clean granulating appearance
of the sore makes it probable that the edges of the divided mem-
brane are in the same state. The business now is to prevent the
incarnation from closing the orifice, for which purpose the end of
the tent may be moistened with spir. vitriol, ten.; or a piece of
lunar caustic so included in a quill, as to leave little more than
the extremity naked, may at each dressing, or every other, or
every third day, be introduced; by which the granulation will be
repressed, and the opening maintained: and when this has been
done for some little time, a piece of bougie of proper size, or a
leaden cannula, may be introduced instead of the tent, and leaving
off all other dressing, the sore may be suffered to contract as much
as the bougie will permit, which should be of such length, that one
extremity of it may lie level with the skin in the corner of the
eye, and the other be within the nose.
The longer time the patient can be prevailed upon to wear the
lS)Ougie, the reore likely will be the continuance of the opening;
and when it is withdrawn, the external orifice should be covered
only by a superficial pledget or plaster, and suffered to heal under
moderate pressure.
There is another method which has been much recommended
by some French writers to prevent the closing of the opening in
the OS unguis: which is, to introduce a cannula either of gold or
silver, or lead, into the aperture, and to permit the sore to heal
over it, suffering the cannula to remain, or to come away by the
nose.
214 • OBSERVATIONS ON THE, StC.
For my own part, I cannot say any thing to it, having never
had occasion to try it; the cases of this kind which I have had
under my direction, having generally succeeded under some of the
methods already mentioned; which methods will frequently prove
successful, if the surgeon is clear in his attention, pursues it
steadily and properly, and refrains from doing too much; fhough I
must again repeat what I have said before, viz. that there is no
method of treating this disorder which is infallible, none that will
absolutely and in all cases prevent a return, especially in scrophu-
lous habits; yet, when a just distinction is made between those
cases which are in their own nature incapable of cure, and those
which by being improperly treated are not cured, I am inclined
to believe, that the number of the former will be found much
smaller than it is generally imagined.'
■ It must appear to whoever has perused the foregoing tract, that the author
took great pains and bestowed much attention on it. His accurate descrip-
tion of the disease rescued it from the obscurity with which it had been
enveloped; and the method of cure which Mr. Pott proposed, was a great
improvement on the awkward, painful, and destructive operations which
had been practised by Mr. Chesselden, and others of his predecessois.
But I must confess that I never was perfectly satisfied with it: I attended
many of these cases with Mr. Pott, and in several the artificial passage
through the os unguis became obliterated soon after the bougie was left
off, though it had been worn a considerable time ; in consequence of which
sometimes a fresh collection of mucus was formed, producing inflammation
and suppuration. In others, where no great inflammation ensued, the
tears, not finding a passage, again took their course down the cheek. It was,
however, as before observed, a great amendment on the operations which
had preceded, and has laid the foundation of the improvements which have
taken place since the time when it was written.
The introduction of metallic tubes, which have been since recommended
by other writers, have also been found inadequate to the purpose, as either
from the tubes shifting their position, or from their being filled with inspis-
sated mucus, the tears were prevented from passing.
The nail-headed style which Mr. Ware has recommended in his valua-
ble work on the fistula lachrymalis must be allowed to be a great improve-
ment, and in my opinion the best method of treating the complaint. The
opening for the introduction of the style is small. The style acts as a capil-
lary tube, by attraction, and readily conducts the tears into the nose — it may
be taken out as often as it may be necessary to clean it, and the duct may be
washed by a syringe — the style may be worn as long as may bethought neces-
sary, as it creates little disfigurement, appearing only as a small black
patch. E.
SOl^E FEW
GENERAL REMARKS
ON
FRACTURES AND DISLOCATIONS.
ON
FRACTURES AND DISLOCATIONS.
No part of surgery is thought to be so easy to understand, as
that which relates to fractures and dislocations. Every the most
inexpert and least instructed practitioner, deems himself perfectly
qualified to fulfil this part of the chirurgic art; and the majority
even of these are affronted by an offer of instruction, on a subject
with which they think themselves already so well acquainted.
Tl^is is also the opinion of a considerable part of the people.
They regard bone-setting (as it is called) as no matter of science;
as a thing which the most ignorant farrier may, with the utmost
ease, become soon and perfectly master of; nay, that he may re-
ceive it from his father and family as a kind of heritage. We all
remember the great, though short-lived reputation, of the late Mrs.
Mapp. We all remember, that even the absurdity and imprac-
ticability of her own promises and engagements were by no means
equal to the expectations and credulity of those who ran after her;
that is, of all ranks and degrees of people, from the lowest labourer
or mechanic, up to those of the most exalted rank and station;
several of whom not only did not hesitate to believe implicitly the
most extravagant assertions of an ignorant, illiberal woman; but
even solicited her company; and, at least, seemed to be pleased
with her conversation.
The desire of health and ease, like that of money, seems to put
all understandings', and all men, upon a level; the avaricious are
duped by every bubble; the lame and the unhealthy by every
quack. Each party resigns his understanding; swallows greedily,
and for a time believes implicitly, the most groundtess, ill-founded,
VOL. r. E e
218 REMARKS ON FRACTURES
and delusory promises; and nothing but loss and disappoint-
ment ever produce conviction. Arts, trades, and manufactures,
are allowed to be learnt, in general, by those who have employed
a proper quantity of time and attention in such pursuits; and it
seems most singularly unjust, as well as untrue, to suppose that
medical people are the only part of mankind who are all either so
dull as not to be able to learn; or so profligately wicked, as not to
practise their art to the best of their judgment, and to the greatest
possible advantage to mankind. Surely there are, and always
have been among us, as well as in all other classes, men truly able
and perfectly honest; men, who well understand the science which
tliey profess; and who practise it not only with great ability, but
with strict integrity. I cannot be supposed to say or to mean this
as a vindication of every individual. Different men have different
powers and capacities. The multitude with us, as with all ranks
and degrees, (not excepting any,) will always be deficient. Ad-
vancements in knowledge will always be owing to the ingenuity
and industry of a few particular people; but such advancements
will always, in due time, more or less influence the rest. They
have so done; and notwithstanding that there remains a great
deal yet to be done, to bring surgery to that degree of perfection
of which it is capable, yet whoever will compare the present prac-
tice of it with that of a very few years ago, cannot justly, or with
any decree of candour, withhold his commendation from his con-
temporaries.
I remember, some years ago, to have heard a judge from the
bench tell a jury, th.it he believed a country bone-setter knew full
as much, if not more of the matter of his own business, tlian any,
the most eminent surgeon in the kingdom. I will not enter into
a disquisition concerning the validity of a judge's opinion. Perhaps
his lordship might very little understand the thing concerning
which he decided so peremptorily: without either injustice or
partiality, I may certainly suppose him to have been a much more
able lawyer than surgeon; and I believe it will also be allowed,
that general reflexions of this kind are, and must be, the conse-
quences of a petulant attempt to be witty, rather than of convic-
tion; and therefore, at best, are frivolous and idle. But, on the
other hand, I am very willing to allow (what indeed I have already
AND DISLOCATIONS.
S19
allowed) that many parts of surgery are still capable of consider-
able improvement; and this part, perhaps, as much as, if not
more than, any; it being one of those in which a general observ-
ance of, and rigid adherence to, old prescribed rules, have pre-
vented the majority of practitioners from venturing to think for
themselves; and have induced them to go on in a beaten track,
from which they might not only safely, but advantageously
deviate.
The general doctrine, relative to fractures, is contained under
tlie following heads, as parts of the treatment of them:
Extension.
Counter-extension.
Coaptation, or setting,
Applicaiion of medicaments.
Deligation, or bandage.
Position.
• Prevention, or relief of accidents.
This is the general arrangement of the subject by most of the
writers on it, and a very just and proper one it is; but notwith-
standing the parade of books under these various heads, much less
alteration will be met with, since the times of Hippocrates, Galen,
and Celsus, than an inquirer might expect, or than the subject is
capable of.
I must desire that what I have said may not be misconstrued.
I do not mean that there are not, and have not at all times, been
men of particular ingenuity, who have deviated from the common
methods, and have greatly improved the art; but still the com-
mon methods are the same, and the multitude of practitioners re-
ligiously follow them. Let me not therefore be charged with pre-
sumption or arrogance, if I say, that under almost every of the
foregoing heads the practice is capable of considerable improve-
inents — improvements, which would show rationality and sense
in the surgeon, and produce ease and convenience to the patient.
I am aware that some of my readers may be inclined to charge
me with affecting to deviate from the commonly prescribed rules;
220 REMARKS ON FRACTURES
and to contradict opinions, which a great length of time, and a
Ipng successsion of writers have given sanction to.
" Imberbes dkUcere, senes perdenda fateri ;"
is a hard lesson sometimes to human vanity, and what requires
some degree of candour to learn. But, on the other hand, if it
was not now and then practised, I know not how such an art as
surgery (whose basis is experience) could ever be improved. Our
ancestors deserve our best thanks for the assistance which they
have given us: where we find them to be right, we are obliged to
embrace their opinions as truths; but implicit faith is not required
from man to man; and our reverence for our predecessors must
not prevent us from using our own judgments. Ancient and mo-
dern are mere sounds, and can signify nothing in this case, un-
less with the former we can connect an idea of truth established
and confirmed by time and experience, and with the latter, that
of demonstrable improvement upon what has gone before^
If what I have to urge is not capable of being verified and con-
firmed by experience, it must sink into nothing; but if, upon trial,
it shall be found by the majority (as it has been by me and some
otlrers) to be not only true and practicable, but highly conducive
to the ease and benefit of the aiflicted, it ought to have as much
weight, though delivered by a living writer, as if it had proceed-
ed from the remotest antiquity: its use, not its date, should give
it value. If practitioners, since the time of Albucasis, had been
contented with his doctrine, and never had ventured to think for
themselves, surgery had not been what it now is, and its great
merit would still have consisted in the multiplicity of its hot
irons. In short, to such as think that we are seldom or never to
deviate from the opinions and practice of those who have gone
before us, I shall take the liberty of answering in the words of
the great Mr. Locke, who says, " The floating of other men'»
" opinions in our brains, makes us not one jot the more know-
" ing, though they happen to be true. And beaten tracks lead
" those whose thoughts reach only to imitation," ' Non quo eun-
' dem est, sed quo itur.'
AND DISLOCATIONS. 221
Before I enter on the subject, the reader will give me leave to
acquaint him, that it is by no means my intention to write a re-
gular treatise on fractures, although I think the subject well de-
serving of, and even requiring one. I only mean to throw out a
few hints, which I hope may prove intelligible and useful.
The first article, in the general arrangement, is extension; un-
der which may also be comprehended the second, or counter-
extension.
In order to accomplish this, we are directed, if the fracture be
of the thigh or leg, to place the patient in a supine posture, and
the broken limb in a strctight one; then, having the upper part of
it held firm and steady, by proper assistants, we are ordered, by
means of hands, ligatures, lacs, or even in some cases by pieces
of machinery, to make such an extension or stretching of the
limb lengthways, as shall enable the surgeon to place the ends of
the broken bone in as apt, that is, in as even a position, with regard
to each other, as the nature of the fracture will admit. This is
a short description .of what, in the vulgar phrase, is called setting
a broken bone; and is most commonly a painful operation to the
patient, a fatiguing one to the operator and his assistants; and
what is worse, is, in many instances, found to be inefficacious; at
least, not fully to answer the intention of the one, or the expecta-
tion of the other.*
Writers in general are very precise and formal in the direc-
tions which they have given for the due and proper accomplish-
» " Instruments for extension are threefold ; first, the surgeon's hands, &c. ;
" secondly, fuues and habenae, a sort of bandage fit to pluck at, in order for
" extension ; thirdly, there are organa and machinenaata, engines used by us,
" and invented by the ancients,"
WiSEMAIf.
The very mention of funes, haben«, organa, and machinemata, implies a
force exceeding that of mere hands; a degree of force, which in a fracture
never can be wanted if the limb be I'ightly placed ; a degree of force which
must, in the nature of things, do mischief; and a degree of force, whose
whole effect, however great, must cease immediately upon its being remov-
ed; unless the fracture be particularly and luckily circumstanced.
There are not wanting instances of the muscles surrounding a bad though
simple fracture, having been torn by extension ; and spasm and other mis-
chief thereby produced. See cautions on this subject, laid down by many
old writers, particularly by Galen and Albucasis.
223 REMARKS ON FRACTURES
ment of this purpose. They have toltl us, that the extension should
be made slowly and gradually; and should be continued till ihe
ends of the bone are separated from each other sufficiently to ad-
mit of the fracture being set without risk of breaking off any
points or inequalities, and to enable us to place them perfectly
smooth and even. All this, like many other of the preceptive
parts of physic and surgery, is very pretty on paper, but not often
found to be practicable in the chamber. The direction to con-
tinue the extension until the ends of the bones are at a certain
distance, lengthways from each other, plainly implies a consider-
able degree of violence; the limb must by such force be not only
made longer than its fellow, or than nature ever intended it
should be, but this procrustian method of lengthening it is ordered
to be executed while the limb is in such position as to put all the
muscles most on the stretch, and render them least likely to yield
to it. Now, not to say a word of the great probability of the points
and edges of the fracture wounding the surrounding muscles, or of
such wounds being more painful, or worse in their consequences,
when inflicted on parts thus stretched, or of the addition that
such force must make to the laceration already necessarily made
by the fracture; I say, not to mention a word of all this, can the
method itself (without considering any accidental, adjunct cir-
cumstances) be practised in every fracture, or even in the majori-
ty of fractures.? Will it be done properly by the rude, the inatten-
tive, and the ignorant? If attempted by such, will it not be, is it
not, frequently productive of pain, tumefaction, inflammation, and
extravasation; which are set to the account of the nature of the
fracture, and to inevitable necessity? and when done ever so pro-
perly, will it, can it, in an oblique or splintered fracture, answer
the purpose it is intended for, or produce a more happy coaptation?
Whence arise these evils ? from whence proceed the difficulty
and the so frequent disappointment?
In order to understand this rightly, let us for a moment con-
sider, what is or ought to be meant by the terms extension and
counter-extension, and why they become necessary: for if the
greater part of the pain attending such method, and the frequency
of disappointment, both to patient and surgeon, should be found
to arise from this part of the process; and that such part can be
AND DISLOCATIONS. 223
either disused without prejudice; or altered with advantage, we
oughl to think ourselves hoppy in having it in our power to correct
our error.
Neither extension, nor counter-extension, can ever be neces-
sary, on account of the mere fracture, considered abstractedly.
The broken ends of the bone or bones are of themselves inactive;
and, if not acted upon by other parts, they would always remain
motionless. When any attempt is made to put them into motion,
they of themselves can make no possible resistance; nor can any
be made on their part, save an accidental one arising from the points
of the fracture being entangled with each other; and when they
have been once, by the hand of the surgeon, placed properly and
evenly with regard to each other, they would of themselves for
ever remain so. What then is the reason why fractured bones
always suffer a greater or a less degree of displacement? why is a
broken limb almost always shorter than its fellow? what creates the
resistance which we always find in attempting to bring the fractured
parts aptly together? whence does it proceed, that when we have
done all that is in our power, (according to this mode of acting,) the
ends of the fracture will, in many cases, become again displaced,
and lameness and deformity frequently ensue? In short, what are
the parts or powers which act on the bones, and which, by so
acting on them, produce all these consequences ?
These parts are the muscles, the only moving powers in the
animal body. By the action of these on the bones, all locomotion
is performed, and cannot be performed without them; and although
all bones, when broken, are in some degree displaced and short-
ened, yet it will always be found, that in proportion as the mus-
cles surrounding, or in connexion with a bone, are strong or nu-
merous, or put into action by inadvertence or spasm, so will the
displacement of the ends of such bone, when fractured, be. The
even and smooth position of the fractured ends of a tibia, when
the fibula of the same leg is entire and unhurt; that is, when the
muscles therefore cannot act upon the former; the visible and im-
mediate deformity, when both the before mentioned bones are
broken nearly in the same place; that is, when the muscles can
act upon, and displace such fracture; the great difficulty fre-
quently met with, in endeavouring to get a broken os femoris to
224: REMARKS ON FRACTURES
lie even tolerably smooth, and to prevent such broken Hmb from
being much shorter than the other, are, among others vi'hich might
be produced, such strong, and irrefragable proofs, as need no
comment.
From the muscles then, and from them only, proceeds all the
difficulty which we meet with in making our extension; and by
the resistance of these, and of these only, are we prevented from
being always able to put the ends of a fractured bone immediately
into the most apt contact.
Let us in the next place consider, what it is which gives to a
muscle, or to the principal muscles of a limb, the greatest power
of resisting any force applied to them ab externo, in order to draw
them out into greater length; for whatever that is, the same thing
will be found to be the cause of the different degrees of resistance
in setting a fracture.
Does not the putting the muscles in a state of tension, or into
a state approaching nearly to that of tension, almost necessarily
produce this effect? or, in other words, does not that position of a
limb, which puts its muscles into, or nearly into such a state, give
such muscles an opportunity of exerting their greatest power
either of action or of resistance? This I believe cannot be denied.
On the other hand, what is the state or position of a muscle which
is most likely to prevent it from acting, and to deprive it most of
its power of resistance? or what is that position of a limb, which,
in the case of a broken bone, will most incapacitate the muscles
from acting on, and displacing it; and in the greatest degree re-
move that resistance which they have it in their power to make
to the attempts for the reduction of such fracture? Is it not
obvious, that putting a limb into such .'position as shall relax the
whole set of muscles belonging to or in connexion with the bro-
ken bone, must best answer such purpose? Nothing surely can
be more evident. If this be granted, will it not, must ij. not fol-
low, that such posture of a broken limb must be the best for
making the reduction; that is, it must be that in which the muscles
will resist the least, and be least likely to be injured; that in
which the broken bone will be most easily set, the patient suffer
least pain in present, and that from which future lameness and
deformity will be least likely to happen. A little attention to
AND DISLOCATIONS. 22$
what frequently occurs, may perhaps serve to illustrate and con-
firm this doctrine better than mere assertion.
What is the reason why no man, however superficially ac-
quainted with his art, ever finds much trouble in setting a fractured
OS humeri, and that with very little pain, and a very small degree
of extension? Is it not because both patient and surgeon concur in
putting the arm into a state of flexion; that is, into such a state as
relaxes all the muscles surrounding the broken bone? and is it not
for the same reason that we so very seldom see (comparatively
speaking of this bone with others) a deformity in consequence of a
fracture of it? Let the reduction be attempted with the arm ex-
tended from the body, and the difficulty of setting will be much
increased: let the arm be deposited in an extended straight position,
and the fracture will be displaced and lie uneven.
Apply the same kind of reasoning to the os femoris; that
bone whose fracture so often lames the patient and disgraces the
surgeon.
Will it not be more cogent, and more conclusive, in proportion
as the muscles in connexion with this bone are more numerous and
stronger?
I would ask any man, who has been much conversant with
accidents of this kind, what is the posture which almost every
person (whose os femoris has been newly broken) puts himself
into in order to obtain ease, until he gets proper assistance? Do
such people stretch out their limb, and place their leg and thigh
straight, and resting on the calf and heel? I believe seldom or
never. On the contrary, do not such people almost always bend
their knee, and lay the broken thigh on its outside? And is not
the reason, why this must be the most easy posture, obvious?
From want of attention to, or from not understanding these few
self-evident principles, many people permit their patients to suffer
considerable inconvenience, both present and future.
It is a maxim universally taught and received, that a fractured
linVu may be in such state, as not to admit of the extension neces-
sary for its being set; that is, if assistance be not at hand, when
the accident happens; if they who bring the patient home, do it
so awkwardly or rudely as to bruise and hurt the part; if from
drunkenness, folly, or obstinacy in the patient, it happens that the
VOL. I. j< f
226 KEMAKKS ON FRACTURES
limb is so disordered that it is found to be much swollen, inflamed, *
and paiafu!, it is allowed not lo be in a state to admit extension.
This, I say, is a general maxim, and founded upon very just
principles; but what is the general practice in consequence of it?
It is, to place the limb in an extended, straight position, to secure
it in that, and then by proper means, such as fomentation, poul-
tice, &c. to endeavour to remove the tension and tumor. Now, if
it be considered that the swollen, indurated, and inflamed state of
the muscles is the circumstance which renders extension impro-
per, surely it must be obvious, that such position of the limb as
necessarily puts these very muscles in some degree on the stretch,
must be a very improper one for the accomplishment of what
ought to be aimed at. Under this method of treatment, the space
of time which passes in the removal of the tension, is sometimes
considerable; so considerable that a happy and an even coaptation
becomes afterwards impracticable; and then (his accident, which
nine times in ten is capabfe of immediate relief, is urged as an ex-
cuse for unnecessary lameness and deformity.
How then are we to conduct ourselves in such circumstances.*
The nature of the complaint points out the relief. Extension is
wrong; a straight position of the thigh or leg is a degree of exten-
sion, and a still greater degree of it in proportion as the muscles
are in such circumstances as to be less capable of bearing it.
Change of posture then must be the remedy, or rather the placing
the limb in such manner as to relax all its muscles, must be the
most obvious and certain method of relieving all the ills arising
from a tense state of them; which change of posture will be at-
tended wi;h another circumstance of very great consequence;
which is, that the bones may in such posture be immediately set,
and not one moment's time be thereby lost; a circumstance of
great advantage indeed! for, whatever may be the popular or pre-
vailing opinion, it is demonstrably true, that a broken bone can-
not be too soon put to rights; as mnsi appear to every one who
will for a moment consider the necessary state of the muscles,
tendons, and membranes surrounding, and the medullary organs
con ained within a large bone broken and unset; that is, iyiiig in
an uneven irregular manner. Can any truth be more clear, ihan
that if the fracture, tension, and tumefaction be such that the mus-
AND DISLOCATIONS. 227
cles cannot bear to be stretched out in the manner necessary for
setting :he broken bone without causing great pain, and perhaps
bringing on still worse symptoms, the more the px)sition of that
limb makes its muscles approach toward a state of tension, tbe
less likely it must be that such symptoms should remit, and the
longer it must be before the wished-for alteration can happen; and
consequently, that while the accomplishment of such purpose is
by every other means aimed at, the position of the limb ought
most certainly to contribute to, and not to counteract it? In short,
if the experiment of change of posture be fairly and properly
made, the objections to immediate reduction, from tension, tumour,
&c. will most frequently be found to be groundless; and the frac-
ture will be capable of being put to rights, as well at first as at any
distance of time afterward. **
Extension having been made, and the broken ends of the bone
having been placed as smooth and as even as the nature of the
'' Mr Pott's recommendation, to lose no time before a broken bon^ is re-
duced or set, ought to be adopted by ever)' practitioner ; and I earnestly ad-
vise, that whoever is sent for to a fractured bone, should never leave it until
he has set it, or placed it in the best possible position. I have often heard
surgeons say they did not attempt to set a fracture at first, because there was
too much inflammation ; and I have, in such cases, found the limb lying on a
pillow, without even the support of a splint, or at best with a splint placed
under a thick pillow, where it could not act; as if splints were entirely use-
less until the fracture was perfectly reduced. Tliis is a very serious error;
for supposing the bones not completely set, splints, properly applied, must
undoubtedly give some stability, and tend, in some degree, to prevent the
motion of the broken bone until it is set; and which efi'ect nuist be lost
through the intervention of a pillow. I will not say, that after a certain time
has passed sulisequent to the accident, and owing to some of the circum-
stances which Mr. Pott has enumerated, a limb may not be so disordered, so
swollen, inflamed, and painful, that it would be imprudent, and probably im-
possible, immediately to alter its position. In that case, we must wait, until,
by the assistance of fomentations, poultices, or other proper applications, 3
favourable alteration takes place ; but these circumstances must indeed be
veiy pressing, and the inflammation very great, which can warrant the not
endeavouring to get the ends of the bones into a proper position the first time
of Seeing the fracture; as it is a true and positive fact, that what is most
likely 10 reduce the swelling and inflammation, and far beyond all topical
applications, is the even and happy position of the ends of the brokon
bones. E.
328 REMARKS ON FRACTURES
case will admit, the next circumstance to be attended to is the
application of some medicament to the limb; particularly to the
fractured part of it. In this, different people act differently.
Some make use of an adhesive, or what they choose to call a
roborant plaster; some, of what is commonly called a cerecloth;
others apply spirit, vini, with oil, vinegar, and white of egg; and
others the spirit, mindereri, the solution of crude sal ammoniac in
vinegar and water, or some such kind of medicine.
To the cerecloth, provided it neither sticks to the skin, nor is
capable of irritating it, there can be no objection; neither can
there be any to all the others, except the adhesive plaster: that
must for ever be wrong upon every rational principle. The in-
tention in applying any kind of external medicine to a broken
limb, is, or ought to be, to repress inflammation, to disperse ex-
travasated blood, to keep the skin lax, moist, and perspirable,
and at the same time to afford some, though very small, de-
gree of restraint or confinement to the fracture, but not to
bind «or press; and it should also be calculated as much as pos-
sible to prevent itching, an herpetic eruption, or an erysipelatous
efflorescence. Adhesive plasters of all kinds, let the composition
of them be what it may, are, from this one quality, the least likely
to contribute to any of the good ends proposed, and the most likely
to be the cause of the contrary inconveniences, which ought most
carefully to be avoided. They obstruct perspiration, they heat the
skin, tliey produce itching, eruption, and inflammation; and if the
fracture be quite surrounded by them, and the limb be from any
cause ever so little inclined to swell, they make a tight, painful,
and pernicious stricture, much greater even than a roller, and less
likely to relax. At St. Bartholomew's hospital, we use a cerate
made by a solution of lytharge in vinegar, which, with soap, oil,
and wax, is afterward formed into such consistence as just to ad-
mit being spread without warming.
This lies very easy, repels inflammation, is not adherent, comes
off clean, and very seldom if ever irritates, or causes either herpes
or erysipelas. But let the form and composition of the applica-
tion made to the limb be what it may, one thing is clear; viz. that
it should be put on in such manner, as that it may be renewed and
shifted as often as may be necessary, without moving the limb in
AND DISLOCATIONS. 229
any manner: it being certain, that when once a broken thigh or
Jeg has been properly put to rights, and has been deposited pro-
perly on the pillow, it ought not ever be lifted up or moved from
it again without necessity, until the fracture is perfectly united;
and it is as true, that such necessity will not very often occur.
This may perhaps seem strange to those who are accustomed to
roll simple fractures, and consequently to lift them up every three
or four days, in order to renew such kind of bandage: but the
necessity af this motion arises merely from the kind of bandage
made use of, and not from any circumstance of the fracture itself
That the frequent motion of a fractured limb cannot possibly con-
tribute to the ease of the patient, will I suppose, be readily admit-
ted; as I suppose also it will, that when a broken limb has been
once deposited in the best position possible, it is impossible to
mend that position; merely by taking such limb up and laying it
down again; from whence it must follow, that such kind of appa-
ratus as necessitates the surgeon frequently to disturb the limb,
cannot be so good as one that does not; provided the latter will
accomplish the same kind of cure as the former: the truth of
\vhich position will appear in the most satisfactory manner to any
who will take a view of the method in which simple fractures are
treated at the before-mentioned hospital. Such application hav-
ing been made as the surgeon thinks right, the next thing to be
done is to put on a proper bandage. That used by the ancients,
and by the majority of the present practitioners, is what is com-
monly called a roller. This is of different length, according to
the surgeon's choice, or as it may be used in the form of one, two,
or more pieces. Hippocrates used three°; Celsus, six; but the
present people seldom use more than one. By such kind of band-
age three intentions are aimed at, and said to be accomplished; viz.
to confine the fracture, to repress or prevent a flux of humours, and
to regulate the callus"^: but whoever will reflect seriously on this
« See on this subject Fab. ab Aquapendenle, Wiseman, Sculletus, Hildanus,
Petit, Du Verney.
••."On applique la premiere sur I'enclroit meme de la fracture. Son
'• milieu doit repondre au centre. On fait trois tours circiiliiires : ce qui
" sert affermir cet endroit, qui est le seul qui ait besoin d'etre assvijetti,
" comrae etant le seul qui peut se deranger, et a contmir le sue nouncier, et
230 REMARKS ON FRACTURES
matler will soon be convinced, that although some sort of band-
age is necessary in every simple fracture, as well for preserving
some degree of steadiness to the limb, as for the retention of the
applications, yet none, nor neither of these three ends can be
answered merely, or even principally, by bandage of any kind
whatever; and therefore, if this should be found to be true — that
is, if it should appear that whatever kind of deligation be made
use of, it cannot be a principal, but only an accessorial kind of
assistance, and that in a small degree, and very little to be de-
pended upon — it will follow, that such kind of bandage as is most
difficult to be applied with justness and exactitude, such as is
soonest relaxed and out of order, such as stands most frequently in
need of renewal, and in such renewal is naost likely to give pain
and trouble, must be more improper and less eligible than one
which is more easily applied, less liable to be out of order, and
which can be adjusted without moving the limb.
The ancient method of applying the roller in case of simple
fracture of the leg or thigh, was to make' four or five turns round
the fracture first, and then to continue the bandage upward and
downward, until the whole limb was enveloped properly. This
was done in this manner with a double view; to keep the broken
ends of the bone in their place, and to prevent the influx of hu-
mour. Modern practitioners, although they have the same ends
in view, generally begin their bandage from the inferior extremity
of the limb, and continue it up to the top. Whether the old or the
later method be followed, whether one or more rollers be made use
of, the whole is executed while the limb is kept by means of the
assistants in the same extended posture in which the coaptation
was made, so that the whole bandage is finished before the leg is
deposited on the pillow; in the doing all which, if from the tired
state of the surgeon,* or either of his assistants, or if from the
" empecher qii''il ne s'echappe tvop abondamment et trap irrc^iilieremcnt a Pentour
" de la fracture ; ce qiiiferoit un cal tres diffhrme."
Du Vf.uxet.
eSee a particular account of this in Fab. ab. Aquapendente, and in Ser-
geant Wiseman.
* T'lie extraordinary length of time used by some in putting a fracture t»
rights, renders what 1 have called the tired state of the assissants an object of
AND DISLOCATIONS. 231
awkwardness, or unhandiness of any of the parties concerned, the
true and exact position of the limb be at all deviated from, the
ends of the bone will again be in some degiee displaced, and the
bandage, instead of being of use, will become prejudicial, by
pressing hard on the inequalities of the fracture: to which let me
add, that the roller, especially when applied to a leg, if it be not
put on with due dexterity, that is, if it do not sit perfectly smooth
and even, is the most unequal and worst kind of bandage in use.
These objections, however just, are not the least to which the
roller in the case of simple fracture of the leg or thigh are liable;
for, as I have already hinted, it must in a very short space of
time, even while the parts surrounding the fracture are in the
most tender and most painful state, be renewed, and that more
than once, which renewal cannot be executed without again tak-
ing the limb off from the pillow, again committing it to the hands
of assistants, and again running a risk of displacing the fracture:
all which, not to mention the repetition of pain to the patient
every time such operation is performed, and which must be at
least every four or five days, are (as I have already said) very
material objections to the roller, even in the most judicious and
dexterous hands, and still more so in those of the rude and igno-
rant.
The prevention of a flux of humours to a broken limb by
bandage, is a common phrase; but they who use it, have either no
idea at all annexed to it, or a very erroneous one.
If by the points and edges of the broken bone, the muscles and
membranes be unavoidably wounded and torn, or if the same kind
of mischief be incurred by the inadvertence or indiscretion of the
patient, or of those who assisted in getting him home, or from the
violence used in extending the limb and setting the fracture, inflam-
mation must be excited, and pain and tumefaction will be the con-
sequence; and these will continue for some time in every fracture;
but that space will be longer or shorter in diflerent cases and un-
der different circumstances: evacuation, rest, and a favourable
importance. The good position of the fracture depends as much or more on
tlfem than on the surgeon. If the assistant who holds the foot varies fi-om
the proper manner, I defy the surgeon to redress the fracture without the
concurrence of such assistant.
232 REMARKS ON FRACTURES
position of the limb, will, and do in general, remove all these
complaints; but bandage can contribute nothing more than by
keeping the applications in their proper place; so far from it, that
if the bandage be a roller, it must by the frequent necessity of its
being adjusted, and the frequent motion of the limb, in some de-
gree counteract the proper intention of cure.
The old writers are in general very precise as to the number of
days during which the roller should be suffered to remain without
being shifted; and the number of times which such shifting should
be repeated within the first fortnight.g This exactitude is by no
means necessary; but if the bandage be supposed to be of any use
at all, it is obvious, that it ought to be renewed or adjusted as
often as it may cease to perform the office for which it is designed,
or whenever it shall be found to counteract such office; that is, as
often as it shall become so slack as not to contain the fracture at
all; or whenever the limb shall be so swollen, that the roller
makes an improper degree of stricture. The former generally
occurs every four or five days: the latter is most frequeni within
the first week.
In most of the writers on the subject of fractures, we also find
marks or signs laid down for our information concerning the due
or undue effect of the bandage on the limb. They tell us, that
when that part of it which is below the termination of the roller
does not swell at all, that the bandage is not sufficiently strict,
and will not retain the fracture; that when the same part is con-
siderably swollen, or tense, or inflamed, it implies, that the bind-
ing is too straight; and that a moderate degree of tumefaction is a
sign that the deligation is properly executed.'^
« **Tertio die a deligatione facta, Hippocrates fascias resolvit, &c. Facta
" bona deligatura et pruritu non insectante, a tertio usque ad septimum opor-
" tet aegrum deligatum detinere.
" Septimo membrum rursus solvendum, perfundendum aqua tepida, et
*f ligandum.
Fab. AB AatTAPENBEKTE.
* See on this Fab. ab Aquapendente, who speaks or rather copies the sen-
timents of Hippocrates and Celsus. " Terminus in stringendo debet esse
" bonalaborantis tolerantia: ut deligatum leviter premat, et sic turn contineat
" et stabiliat fracturam, turn humores exprimat. Sunt eliam alia luijus signa,
" qux altero die apparent ; si enim scger eo die quo deligatus sentiat se valen-
AND DISLOCATIONS. 233
In consequence of these precepts, many practitioners look more
anxiously after this degree of tumefaction, than after the true and
exact position of the limb; and cannot be induced to believe, that
imy thing can be wrong under this appearance; although, if they
would for once assume the liberty of thinking for themselves,
they might be convinced, that even this degree of swelling is
wrong; that it implies some kind of obstruction to the circulation,
and cannot serve any good purpose; and consequently, that as far
as it may be supposed to be the effect of bandage, so far that band-
age must be faulty.
The third purpose for which the roller is said to be used, is the
regulation and restraint of the callus.
If we were to form our notion of callus by what the generality
of writers have said on this subject, we should suppose, that it was
not only a particular juice always ready for the purpose, but that,
if not restrained and regulated by art, it would always flow in
such quantity, as to create trouble and deformity; that there were
specific remedies for increasing or decreasing it; and that it al-
ways required the hand and art of surgery to manage it. That
the callus is so far a particular juice, as that it consists of what-
ever is destined to circulate through the bones for their particular
Bourishment, is beyond all doubt; and that this gelatinous kind of
fluid is the medium by which fractures are united, is as true; but
that it requires art to manage it, or that art is in general capable
of managing and directing it, is by no means true. That this
callus or uniting medium does oftentimes create tumefaction and
deformity, or even lameness, is true also; but the fault in these
cases does not lie in the mere redundance of such juice; it is de-
rived from the nature of the fracture, from the inequality of it
when set, and from the inapt position of the broken ends with
regard to each other; nor is surgery or the surgeon any otherwise
•• tius stringi, postero vero die tumor laxus, mollis et parvus appareat, bona
" est deiigatio, quia jam humores a parte fracta sunt expressi. Si vero aut
" nullus tumor aut magnus et durus postridie in manu vel pede appareat, pra-
" va est deligatura ; quia ilia non continet, haec vero nimis arcta est et inflam-
*• mationem movet. Id notandum, fascias magis stinngi debere in parte fracta
*• quam alibi, ut pars fracta magis illsesa servetur, ab humorum defluxu."
VOL T. G g
234 REMARKS ON FRACTURES
blamable in Ibis case, tban as it was or was not originally in
tbeir power to bave placed tbem better. It is the inequality of
the fracture which makes both the real and apparent redundance
of callus, and the tumefaction in the place of union. When a
bone has been broken transversely, or nearly so, and its inequali-
ties are therefore neither many nor great, when such broken parts
have been happily and properly coaptated, and proper methods
have been used to keep them constantly and steadily in such
state of coaptation, the divided parts unite by the intervention of
the circulating juice, just as the softer parts do, allowing a differ-
ent space of time for different texture and consistence. When
the union of a broken bone under such circumstances has been
procured, the place where such union has been made will be very
little perceptible; it will be no deformity, nor will it occasion any
inconvenience. It will indeed be discoverable, like a cicatrix of
a wound in a softer part; but there will be noredundance of cal-
lus, because none will be wanted: neither will there be any neces-
sity for any particular management, on the part of the surgeon, to
repress or keep it in order. But when a bone has been broken
very obliquely or very unequally, when the parts of a fracture are
so circumstanced as not to admit of exact coaptation, when such
exact coaptation as the fracture perhaps would have admitted has
not been judiciously made, when, from unmanageableness, inad-
vertence, or spasm, the proper position of the limb has not been
attended to or preserved, in all such cases there must be consider-
able inequality of surface; there must be risings on one side, and
depressions on another; and in such cases the juices circulating
through the bone, cannot accomplish the union in the same quan-
tity, the same time, or in the same manner. The broken parts
not being applied exactly to each other, there cannot be the same
aptitude to unite; and according to the greater or less degree of
exactitude in the coaptation, that is, according as the ends of the
bones are, or have been placed more or less even with regard to
each other, will the inconvenience and the deformity be; and sUll
mqre where the fracture is not set at all: but the broken ends of
the bone unite laterally, or by touching each other's sides. The
reason of all this is so obvious, without having recourse to a par-
ticular specific juice under the name of callus, that it would be
J-rmt page 2Si. Vol. J.
En^. by IU'lIi
AND DISLOCATIONS. 2S5
an insult upon the reader's understanding to explain it further.'
The periosteum covering every fracture will remain thickened for
some time, and a degree of fulness or rising will be thereby caus-
ed about the place where such fracture has been united; but time,
and the use of the muscles, soon in general remove this.
In short this doctrine of callus, considered as a particular kind
of juice, and as being liable to great redundance if not prevented
by art, has not only misled many people, but has often been made
use of as a cover to ignorance and neglect. When lameness and
deformity have been the consequences of one or both these causes,
more than of the nature and circumstances of a fracture, the callus
has been found ready at hand to take the blame; and the ideal ex-
■ uberance of this cement has often been urged as an excuse for real
want of knowledge, or for gross neglect.
The best and most useful bandage for a simple fracture of the
leg or' thigh, is what is commonly known by the name of the
eighteen-tailed bandage,'' or rather one made on the same prin-
ciple, but with a little difference in the disposition of the pieces.
The common method is to make it so, that the parts which are to
surround the limb, make a right angle with that which runs
lengthways under it; instead of which, if they are tacked on so as
to make an acute angle, they will fold over each other in an oblique
direction, and thereby sit more neatly and more securely, as the
parts will thereby have more connexion with and more depen-
dence on each other. In compound fractures, as they are called,
every body sees and acknowledges the utility of this kind of
bandage preferable to the roller, and for very obvious and con-
vincing reasons, but particularly because it does not become ne-
cessary to lift up and disturb the limb every time it is dressed, or
every time the bandage loosens.
The pain attending motion in a compound fracture, the circum-
' On the subject of callus, the editor of Du Verney tells a story from Galen,
and which himself seems not to disbelieve, viz. that a callus in a particular
case was so redundant as to transude through the skin, and to keep the com-
presses constantly wet.
" Perhaps more properly the many-tailed bandage, as the number of tails
or ends must depend on the length of the limb, and other circumstances rela-
tive to the fracture. E.
236 REMARKS ON FRACTURES
Stance of the wound, and the greater degree of instability of parts
thereby produced, are certainly very good reasons for dressing
such wound with a bandage, which does not render motion neces-
sary; but I should be glad to know what can make it necessary,
or right, or eligible, to move a limb in the case of simple fracture?
what benefit can be proposed by it? what utility can be drawn
from it? When a broken bone has been well set, and the limb
well placed, what possible advantage can arise from moving it?
surely none; but, on the contrary, pain and probable mischief. Is
it not the one great intention to procure unition? Can moving the
limb every two or three days contribute to such intention? Must
it not on the contrary obstruct and retard it? Is not perfect quie-
tude as necessary towards the union of the bone in a simple as
in a compound fracture? It is true, that in the one there is a
wound which requires to be dressed, and the motion of the limb
may in general be attended with rather more pain than in the
other: but does motion in the simple fracture give ease, or procure
more expeditious union?
Every benefit then wdiich can be supposed to be obtained from
the use of the common bandage or roller, is equally attainable
from the use of that which I have just mentioned, with one ad-
ditional, and, to the patient, most invaluable advantage; viz. that
of never finding it necessary to have his leg or thigh once during
the cure removed from the pillow on which it has been properly
deposited. In short, to quit reasoning and speak to fact, it is the
constant practice at St. Bartholomew's, and attended with all
possible success. We always use the eighteen-tailed bandage;
and never move the limb to renew or adjust it.'
The parts of the general apparatus for a simple fracture, which
come next in order, are the splints.
These are generally made of pasteboard, wood, or some resist-
ing kind of stuff, and are ordered to be applied lengthways on the
broken limb; in some cases three, in others four; for the more
steady and quiet detention of the fracture.
That splints properly made and judiciously applied are very
J See the different- opinions of different French practitioners, with tlieir
reasons on this subject, in Dii Verney, Traite des Maladies des Os.
ANV DISLOCATIO>f^. 237
serviceable, is beyond all doubt; but tbeir utility depends much
on their size and the manner in which they are applied.
In general practice, they are made of such length, as not to
reach either upward or downward, so far as the roller extends';
not to comprehend either the upper or the lower joint of the
broken bone, and to exceed the fracture either way not many
inches. They do not, for example, in the broken leg compre-
hend either the joint of the knee, or the joint of the ancle, and
act only on the fracture.™
In this manner of application, and of this size, they are in fact
neither more nor less than compresses, and compresses made of
very bad materials. All the good that ever is, or that can be
done by them, when of such length and so applied, might cer-
tainly be done in a better manner by a more proper kind of com-
press; and every disadvantage, which a hard resisting compress,
injudiciously applied, is capable of producing, is probable to result
from them thus used.
"' Tliis is the old doctrine, and has been ahnost universally and constantly
adhered to and followed. Our forefathers, finding that siicli splinls as they
used and applied in their manner excited pain and inflammation, did not use,
but forbade them until after seven days were past, and the first inflammation,
as they thought, was over.
After this, they put them on to strengthen the fracture, as they said, and
therefore made them short for that purpose only, expressly cautioning us
against the only method of applying them (in the case of a broken leg) in
which they can be really useful ; viz. that in which they comprehend both the
knee and ancle.
" Feri|larum usus idem est ac pannorum ad fractum os continendum, ut
" maneat immotum, etiamsi membrum universum moveatur.
" Jubet Hippocrates leves esse ferulas et aequales et ad extrema resi-
" mas, &c.
" Sed et breviores ferulas esse prsecipit ipsa vinciwa, ne quando cutem
•" proximam tentare valeant eminentem plerumque ob humores receptos,
" quos fasciae exturbant. Id quoque cavere oportet, ne ad ossium eminentias,
" quales in ima tibia et sura sunt, ferulse pertingant," &.c. &.c. &c.
OuiBASius de Fracturis.
" Sed hoc tempore (post septimum diem) vice plagularum ojiortet ferulas
" opponere.
" His utebatur Hippocrates demum post septimum diem ; quia ante septi-
" mum magis urgebat intentio arcendse inflammationis, quam intentio stabili-
'^ endi fracturam ; post septimum autem contra acciuit."
Fab. AB AaUAPEJfDENTE.
238 REMARKS ON FRACTURES
The true and proper use of splints is, to preserve steadiness in
the whole limb, without compressing the fracture at all. By the
former they become very assistant to the curative intention; by the
latter they are very capable of causing pain and other incon-
veniences; at the same time that they cannot, in the nature of
things, contribute to the steadiness of the limb.
In ofder to be of any real use at all, splints should, in the case
of a broken leg, reach above the knee and below the ancle; should
be only two in number; and should be so guarded with tow, rag,
or cotton, that they should press only on the joints, and not at all on
the fracture.
By this they becbme really serviceable; but a short splint,
which extends only a little above and a little below the fracture,
and docs not take in the two joints, is an absurdity; and, what is
tvorse, it is a mischievous absurdity.
By pressing on both joints, they keep not only them but the
foot steady; by pressing on the fracture only, they cannot retain
it in its place, if the foot be in the smallest degree displaced; but
they may, and frequently do occasion mischief, by rudely pressing
the parts covering the fracture against the edges and inequali-
ties of it.
I suppose it will be said, that although short splints do not of
themselves sustain and keep steady the two joints, and conse-
quently the limb, yet that purpose in the broken leg may be, and
is, fulfilled by junks, fanons, and other contrivances. To which
I answ^er, that then the short splints are in that case of no use at
all, and had better be laid aside: they should be used for no other
purpose, but that of keeping the limb steady; and, if they do not
answer that end, they are an incumbrance, and multiply the arti-
cles in the apparatus for a fractured leg very unnecessarily.
In the case of a fractured os femoris, if the limb be laid in an
extended posture, one splint should certainly reach from the hip
to the outer ancle, and another (somewhat shorter) should extend
from the groin to the inner ancle. In the case of a broken tibia
and fibula, there never can be occasion for more than two splints,
one of which should extend from above the knee to below the
ancle oa one side, and the other splint should do the same on the
AND DISLOCATIONS.
239
other side. The manner of applying them, if the limb l)e de-
posited in a state of flexion, will come under the next article.
This, and indeed the most essential article in the treatment of
a fracture, is the position of the limb. Upon tiie judicious or in-
judicious, the proper or improper execution of this, depends the
ease of the patient during his confinement, and the free use and
natural appearance of his limb afterward.
If I meant to describe, or if I approved (pardon the phrase) the
common method of placing the broken leg and thigh in a straight
manner, this would be the place to mention the many very in-
genious contrivances and pieces of machinery, which practitioners,
both ancient and modern, have invented for the purpose of keep-
ing the whole limb straight and steady; that is, of keeping all the
muscles surrounding the fractured bone constantly upon the stretch,
and at the same time of preventing any inequality in the union
of it, and any shortening of the limb, in consequence of such
inequality.
But as it is my intention by these sheets to inculcate another,
and as it appears to me a better disposition of the limb, in which
such boxes, cradles, and pieces of machinery are not wanted, nor
can be used, it is needless for me to say any thing about them.
According to this plan the fractured leg and thigh should be
deposited on the pillow, in the very posture in which the extension
was made, and the fracture set; that is, with the knee bent.
I have already been so explicit, or perhaps prolix, on the tense
or lax state of the muscles, as depending on posture, under the
head of extension, that I shall spare the reader, as well as myself,
a good deal of trouble by referring back to that article. All that
is there urged, or that can be urged for making the extension, that
is, for setting a fracture in such disposition of a limb or its mus-
cles, is equally powerful and conclusive ivith regard to the man-
ner of depositing and leaving it after it has been set. Whatever
renders reduction and coaptation easy, must as necessarily main-
tain ease during the confinement, preserve rectitude of figure, and
prevent displacement. The same principle must act on both
occasions; and whether the doctrine be right or WTong, considered
by itself, it must be equally so in both circumstances; that is, in
the manner of setting a fracture, and in the r^anner of depositing
240 REMARKS ON FRACTURES
the limb afterwartl." In the case of the fractured os humeri, the
only position in which it can with any tolerable convenience to
the patient be placed, is, with the elbow bent, that very position
which necessarily relaxes and removes all the resistance of the
surrounding muscles. Daily experience evinces the utility of this,.
by our very seldom meeting with lameness or deformity after it,
notwithstanding the prevailing apprehension of exuberant callus.
The deformity frequently consequent to the fracture of the
bones of the cubit, particularly that of the radius only, will gene-
rally, if not always, be found to be in proportion as the muscles
concerned in the pronation and supination of the hand happen to
be put more or less into a state of action, or tension, by the position
of the limb.
In the thi^h, the case is still more obvious, as the muscles are
still more numerous and stronger.
The straight posture puts the majority of them into action, by
which action that part of the broken bone, which is next to" the
knee, is pulled upward, and by passing more or less underneath
that part which is next to the hip, makes an inequality or rising
in the broken part, and produces a shortness of the limb.
In the fracture of both bones of the leg, the case is still the
same; a straight position puts the muscles upon endeavouring to
act; a moderate flexion of the knee relaxes them, and takes off
such propensity."
The disposition, therefore, of the broken cubit ought to be that
which, by putting the hand into a middle state between prona-
tion and supination, and by bending the fingers moderately, keeps
the radius superior to the ulna; or in other words, the palm of the
hand should be applied to the breast, the thumb should be supe-
" It has been said, that the straight position of a limb, by putting the miis-
cles on the stretch, induces t!iem to contribute to the security of the frac-
ture against displacement. If this be the case ih general, how happens it
that those bones are always found most liable to be displaced when broken,
and to be most difficult to keep in their proper place, which are surrounded
by the most, and by the strongest muscles ?
• In proportion as the fracture shall happen to be more or less oblique, the
truth of this doctrine will, upon experiment, be found to be more or less
apparent, 3is well as ujscful.
ANl) DISLOCATIONS. 241
rior, the little finger inferior; and the hand should be kept in this
posture constantly by means of two splints; which should reach
from the joint of the elbow on each side, and should be extended
below the fingers; or the same purpose may be still better an-
swered by a simple neat contrivance of the very ingenious Mr.
Gooch of Norfolk; of which he has given a draft, and which is
preferable to a common splint, by its admitting the fingers to be
more easily bent.
The position of the fractured os femoris should be on its out-
side, resting on the great trochanter; the patient's whole body
should be inclined to the same side; the knee should be in a mid-
dle state, between perfect flexion and extension, or half bent; the
leg and foot lying on their outside also, should be well supported by
smooth pillows, and should be rather higher in their level than
the thigh; one very broad splint of deal, hollowed out, and well
covered with wool,? rag, or tow, should be placed under the
P If tlie pillow on which the broken thigh is placed be not too thick, the
splint may with equal advantage be placed underneath such pillow, and in
many cases this will be found to be the best manner of using it.*
• Of late years Mr. Pott was not partial to the use of pillows ; and I
have often heard him object to their being placed between the splint and the
limb ; indeed, in general, our intentions are better effected without any. I
would take the liberty to recommend, in fractures of the leg or thigh, so
soon as the bones are set, and the limb placed in a proper position on a splint,
that it be gently laid on the bed, previously made firm, smooth, and level. In
this manner it lies on a foundation to be depended on : if a pillow be placed
under a»fractured leg, it elevates it above the level of the body, and the
thigh remains unsupported. If another be placed under the thigh, though
it may in some measure obviate this inconvenience, it is very liable to be
displaced. In general, the elevation of ihe leg, so far from being necessary,
is prejudicial ; the limb will lie with much more ease and security when on
a level with the pelvis : the bed therefore cannot be made too flat. If it be
thought necessary to raise the limb higher, in order to serve any particular
purpose, pillows or double blankets may be very conveniently placed under
the bed : by these means a broad steady basis will still be preserved for the
support of the fractured limb. With regard to applying pillows between
the limb and the splint, I must observe, that they cannot be thus used to
advantage, as they take from the proper stability and pressure of the splint,
and give the fractured ends of the bones too much play. The nearer and
closer the splints are to the limb the better, provided they are prevented
from galling by the interposition of some soft substance, snch aa tmv or
rag. E.
VOL. I. H h
242 REMARKS ON FRACTURES
thigh, from above the trochanter, quite below the knee; and an-
other, somewhat shorter, should extend from the groin below the
kriee on the inside, or rather in this posture on the upper side;
the bandage should be of the eighteen-tail kind; and when the
bone has been set, and the thigh well placed on the pillow, it
should not, without necessity (which necessity in this m thod
will seldom occur) be ever moved from it again until the frac-
ture is united; and this union will always be accomplished in
more or less time, in proportion as the limb shall have been more
or less disturbed.
In the fracture of the fibula only, the position is not of much
consequence; because, by the tibia remaining entire, the figure of
the leg is preserved, and extension quite unnecessary; but still,
even here, the laying the leg on its side, instead of on the calf,
is attended with one very good consequence; viz. that the confine-
ment of the knee, in a moderately bent position, does not render
it so incapable of flexion and use afterward, as the straight or ex-
tended position of it does; and consequently that the patient will
be much sooner able to walk, whose leg has been kept in the for-
mer posture, than he whose leg has been confined in the latter.
In the fracture of both tibia and fibula, the knee should be mo-
derately bent, the thigh, body, and leg, in the same position as in
the broken thigh. If common splints be used, one should be
placed underneath the leg, extending from above the knee to
below the ancle, the foot being properly supported by pillows,
bolsters, &c.; and another splint of the same length showld be
placed on the upper side, comprehending both joints in the same
manner; which disposition of splints ought always to be observed^
as to their length, if the leg be laid extended in the common-way,
only changing the nominal position of them, as the posture of
the leg is changed, and calling what is inferior in one case, ex-
terior in the other; and what is superior in one, in the other in-
ferior.'^
t All writers on this subject agree in giving iis cautions about defending
the heel, and filling up the hollow from it to the calf of the leg; and this
they do on account of the pain, excoriation, and even ulceration, which
sometimes attend the straight position, with the Umb resting on the heel.
. Many of them have also taken notice of an accident sometimes attendant
AND DISLOCATIONS. 343
If Mr. Sharpe's splints be made use of, there is in one of them
a provision for the more easy support of the foot and ancle, by an
excavation in, and a prolongation of the lower or fibular splint,
for the purpose of keeping the foot steady.
I hope that I have expressed my meaning clearly; I should be
very sorry to be mistaken, because it appears to me to be a matter
of some consequence; and if what I have said be intelligible, the
reader will understand from thence, that I mean to signify that
(in my opinion) extension will in general be made with more
facility, and coaptation more happily executed; that a patient will
suffer a great deal less pain during these operations, as well as
during the necessary confinement for a broken leg or thigh; and
that both patient and surgeon will be less likely to be disappoint-
ed in their intention and wish; that is, that the former will be less
liable to lameness or deformity, when a fractured thigh or leg has
been treated in the way I have described, than in the common
one.
The resistance necessarily made by the muscles, joined to the
great instability of parts in every species of fractured leg or thigh,
except in the few where the bones are broken transversely, has
constantly exercised the invention and ingenuity of practitioners,
in devising means to prevent inequality in the callus, as it is called,
and shortness and deformity of the limb. Our books abound
with draughts and descriptions of machines for this purpose; liga-
tures, pullies, leaden weights, and fracture- boxes, so constructed
as to overcome and constantly to resist that action of the muscles
surrounding the broken bone, that natural tendency in them to
contract, which the extended position of the limb necessarily in-
duces. Every body who has been conversant wiih matters of
this sort knows, that even the best of these various contrivances
often prove successless; and every one who will reflect ever so
little may see why they must be so. That they do prove
ineffectual, the number of deformed legs and shortened thighs,
which are daily met with, evinces; and that they must frequently
on a broken leg, but which really ought to be set to the accovxnt of the pes-
ture in which such a leg is placed, more than to tiiat of the fracture : I mean
the shrinking or wasting of the calf.
244 REMARKS ON FRACTURES
prove so will be obvious to every one, who will consider that the
effect can last no longer than the cause is continued, unless there
happens to be some very favourable circumstance in the fracture
itself. What I mean is this, when the reduction of the fracture
is set about, the limb is put into such position, that the surround-
ing muscles resist the extending force very considerably, and this
in proportion to their strength and number; that force is continued
and increased till the muscles give way; and the resistance being
overcome, an opportunity is thereby obtained of placing the ends
of the fracture in as apt position with regard to each other as the
nature of it will admit. If the fracture be of the transverse kind;
that is, if the ends of the broken bone be large, and afford a good
deal of space for contact with each other, such apposition will
contribute a good deal to the keeping the limb steady, and the frac-
ture even; but if the fracture be of the oblique kind, if there be
several loose pieces, and consequently neither large contact nor
stability from the apposition, or if due extension has not been made^
or could not, or if the ends of the bones have not been judiciously
and properly set, the muscles will act as soon as the extension is
relaxed, the fracture will be more or less displaced, according to
the nature of it, the limb will be shortened, the time of union will
be prolonged, and the place of it (the callus, as it is called) will
be in proportion more or less unequal.
I take it for granted that it will be asked, Have not our ances-
tors in all times happily redressed fractured legs and thighs, by
the method which they have delivered down to us, and which in
the preceding pages I have taken the liberty to object to? Have
not such limbs frequently been rendered as straight, as useful, and
as little deformed as possible? I answer, most certainly, yes; it
is an undoubted truth, and cannot be denied. But in my turn, let
me be permitted to ask, whether in the same method great and
even unsurmountable difficulty is not frequently met with? Whe-
ther in many cases the act of setting, as it is called, is not exces-
sively painful at the time, and productive of inflammation and other
disagreeable symptoms afterward? and whether, in spite of all
care, of every contrivance, of every species of machinery which
has yet been used, broken thighs and legs are not often, very
AND DISLOCATIONS. 24^5
often, left deformed, crooked, and shortened, and that merely from
the aciion of the muscles, and the obliquity or shattered state of
the fracture? The fact is notorious, and the sole question is,
whether or no a different disposition of the parts preventing such
action and such resistance, will in many instances prevent these
evils? To which, from repeated experience, I answer, Yes. If
this should be found to be the case in general, of which I make
no doubt that it is; if by this method, many of such unfortunate
cases, as in the common method of treatment, disappoint both-
patient and surgeon, should be found in general to succeed so well
as to satisfy both, it will prove all I wish it should prove. Su-
perior utility and more frequent success are all I contend for.
Many people did very well under amputation before the double
incision was practised; but is the double incision therefore no
improvement? The operation for the bubonocele may be per-
formed with that clumsy instrument the probe scissors, but is the
bistoury therefore not preferable? A surgeon may cut off some
ounces, or even pounds of flesh from a patient's backside, in
order to care a sinus, but is the cure by the simple division of
that sinus therefore not easier or more expeditious? Neither of
these can (I think) be proved, unless it can at the same time be
proved, that pain is no evil, confinement not at all irksome, and
that deformity and elegance of figure are synonymous terms.
Let not the reader fancy that I would dare to amuse him with
speculation, or merely specious reasoning on a subject like this.
What I have said is from experience, repeated experience both
of myself and of others, for a considerable length of time past,
and on a great variety of subjects; from an experience which has
perfectly satisfied me, and I think will every man who will make
the trial fairly and candidly. I do not pretend to say, that by
these means every kind of broken bone will infallibly and cer-
tainly be brought to lie smooth, even, and of proper length; if I
did, they who are versed in these things would know that I said
too much: but I will say, (what is sufficient for my purpose,) that
it will not only succeed in all those, in which the old method
can ever be successful; but also in the majority of those in which
it is not, nor in the nature of things can. Jn those fortunate
c^ses, in which either method will do, the old one is fatiguing,
346 REMARKS ON FRACTURES
inconvenient, and even sometimes offensive, from the supine and
confined posture of the patient; whereas, that which is here pro-
posed, gives the patient much greater liberty of motion for every
purpose either of choice or necessity; and in many of those cases,
wherein the old method proves most frequently so far success-
less, as to leave the limb short, lame, or deformed, I say, in most
of these, the proposed method will not be attended with these in-
conveniencies.
I have already said, that in most cases of broken thigh or leg,
the method just described will be attended with great success:
but there is one particular case in which its utility is still more
conspicuous; a case which, according to the general manner of
treating it, gives infinite pain and trouble both to the patient and
surgeon, and very frequently ends in the lameness and disappoint-
ment of the former, and the disgrace and concern of the latter — I
mean the fracture of the fibula attended with a dislocation of the
tibia.
Whoever will take a view of the leg of a skeleton, will see that
although the fibula be a very small and slender bone,- and very
inconsiderable in strength, when compared with the tibia, yet the
support of the lower joint of that limb (the ancle) depends so much
on this slender bone, that without it the body would not be upheld,
nor locomotion performed, without hazard of dislocation every
moment. The lower extremity of this bone, which descends con-
siderably below that end of the tibia, is by strong and inelastic
ligaments firmly connected with the last-named bone, and with
the astragalus, or that bone of the tarsus which is principally con-
cerned in forming the joint of the ancle. This lower extremity
of the fibula has, in its posterior part, a superficial sulcus for the
lodgement and passage of the tendons of the peronei muscles, which
are here tied down by strong ligamentous capsula;, and have their
action so determined fiom this point or angle, that the smallest
degree of variation from it, in consequence of external force, must
necessarily have consideiable etfect on the motions they are de-
signed to execute, and consequently distort the foot. Let it also
be considered, that upon he due and natural state of the joint
of the ancle, that is, upon the exact and proper disposition of the
tibia and fibula, both with regard to each qther and to the astra-
^h>/i/ ycxTyf S!t7. Vol. J .
^^j:*JJ>//y,'/ur S.'.
AND DISLOCATIONS. 247
galus, depend the just disposition and proper action of several
other muscles of the foot and toes; such as the gastrocnemii, the
tibialis anticus and posticus, the flexor pollicis longus, and the
flexor digitorum pedis longus, as must appear demonstrably to
anj man who will first dissect, and then attentively consider these
parts.
If the tibia and fibula be both broken, they are both generally
displaced in such manner, that the inferior extremity, or that
connected with the foot, is drawn under that part of the fractured
bone which is connected with the knee; making by this means a
deformed, unequal tumefaction in the fractured part, and render-
ing the broken limb shorter than it ought to be, or than its fellow.
And this is generally the case, let the fracture be in what part of
the leg it may.
If the tibia only be broken, and no act of violence, indiscretion,
or inadvertence be committed, either on the part of the patient or
©f those who conduct him, the limb most commonly preserves its
figure and length; the same thing generally happens if the fibula
only be broken, in all that part of it which is superior to letter .^ in
the annexed figure, or in any part of it between its upper extre-
mity, and within two or three inches of its lower one.
I have already said, and it will obviously appear to every one
who examines it, that the support of the body, and the due and
proper use and execution of the office of the joint of the ancle,
depend almost entirely on the perpendicular bearing of the tibia
upon the astragalus, and on its firm connexion with the fibula. If
either of these be perverted or prevented, so that the former bone
is forced from its just and perpendicular position on the astraga-
lus; or if it be separated by violence from its connexion with the
latter, the joint of the ancle \xi\\ suffer a partial dislocation in-
ternally;'' which partial dislocation cannot happen without not only
a considerable extension, or perhaps laceration of the bursal liga-
ment of the joint, which is lax and weak, but a laceration of those
strong tendinous ligaments, which connect the lower end of the
tibia with the astragalus and os calcis, and which constitute in
great measure the ligamentous strength of the joint of the ancle.
" See the figure at the preceding page.
348 REMARKS ON FRACTURES
This is the case, when, by leaping or jumping, the fibula breaks
in the weak part already mentioned; that is, within two or three
inches of its lower extremity. When this happens, the inferior
fractured end of the fibula falls inward toward the tibia, that ex-
tremity of the bone which forms the outer ancle is turned some-
what outward and upward, and the tibia having lost its proper
support, and not being of itself capable of steadily preserving its
true perpendicular bearing, is forced off from the astragalus in-
wards, by which means the weak bursal, or common ligament of
the joint, is violently stretched, if not torn, and the strong ones^
which fasten the tibia to the astragalus and os calcis, are always
lacerated; thus producing at the same time a perfect fracture and
a partial dislocation, to which is sometimes added a wound in the
integuments, made by the bone at the inner ancle. By this means,
and indeed as a necessary consequence, all the tendons which pass
behind or under, or are attached to the extremities of the tibia and
fibula, or os calcis, have their natural direction and disposition so
altered, that, instead of performing their appointed actions, they
all contribute to the distortion of the foot, and that by turning it
outward and upward.
When this accident is accompanied, as it sometimes is, with a
wound of the integuments of the inner ancle, and that made by the
protrusion of the bone, it not infrequently ends in a fatal gan-
grene, unless prevented by timely amputation, though I have se-
veral times seen it do very well without. But in its most simple
state, unaccompanied with any wound, it is extremely troublesome
to put to rights, still more so to keep it in order, and unless ma-
naged with address and skill, is very frequently productive both
of lameness and deformity ever after.
After what has been said, a further explanation why this is so
is unnecessary. Whoever will take even a cursory view of the
disposition of the parts, will see that it must be so. By the frac-
ture of the fibula, the dilatation of the bursal ligament of the joint,
and the rupture of those which should tie the end of the tibia
firmly to the astragalus and os calcis, the perpendicular bearing of
the tibia on the astragalus is lost, and the foot becomes distorted;
by this distortion, the direction and action of all the muscles al-
ready recited are so altered, that it becomes (in the usual way of
AND DISLOCATIONS. 249
treating this case) a difficult matter to reduce the joint, and, the
support of the fibula being gone, a more difficult one to keep it in
its place after reduction. If it be attempted with compress and
strict bandage, the consequence often is a very troublesome, as
well as painful ulceration of the inner ancle, which very ulcera-
tion becomes itself a reason why such kind of pressure and band-
age can be no longer continued; and if the bone be not kept in its
place, the lameness and deformity are such, as to be very fatiguing
to the patient, and to oblige him to wear a shoe with an iron, or
a laced buskin, or something of that sort, for a great while, or
perhaps for life.
All this trouble, pain, difficulty, and inconvenience, are oc-
casioned by putting and keeping the limb in such position as
necessarily puts the muscles into action, or into a state of resist-
ance, which in this case is the same. This occasions the diffi-
culty in reduction, and the difficulty in keeping it reduced; this
distorts the foot, and by pulling it outward and upward makes
that deformity which always accompanies such accident: but if
the position of the limb be changed, if, by laying it on its outside,
with the knee moderately bent, the muscles forming the calf of
the leg, and those which pass behind the fibula and under the os
calcis are all put into a state of relaxation and non-resistance,
all this difficulty and trouble do in general vanish immediately;
the foot may easily be placed right, the joint reduced, and by
maintaining the same disposition of the limb, every thing will in
general succeed very happily, as I have many times experienced.
Two kinds of fracture there are, and only two that I can recol-
lect (relative to the limbs) which do not admit of the bent posi-
tion of the joints; I mean that of the processus olecranon at the
elbow, and that of the patella: in these a straight position of the
arm and leg is necessary; in the former to keep the fractured
parts in contact till they are united; in the latter, to bring them
as near to each other as may best serve the purpose of walking
afterward.'
With regard to the fracture of the patella, an opinion has long
» Although a straight position of the limb Is necessary for the broken pa-
tella, yet this very position becomes so upon the same principle, as renders
VOL. I. I i
250 REMARKS ON FRACTURES
and generally prevailed, which seems to me to have no foundtt-
tion in truth, or (when duly considered) even in probability; it is,
that the great degree of stiffness in the joint of the knee, which
is sometimes found to be the consequence of this kind of fracture,
is owing to, or produced by, a quantity of callus falling into it
from the edges of the broken bone; and that the nearer tire broken
pieces are brought to each other, the, more likely such conse-
quence is.
Every part of this doctrine seems equally absurd. Jn the first
place, the fractured bone is by no means capable of supplying
such a quantity of callus as to produce this end, unless it may be
supposed to run from it as solder from a plumber's ladle; in the
second place, if this was the case, the most likely and indeed the
only probable way of preventing the deposition of such juice,
must be by bringing the broken pieces into close contact; and in
the third place, there is no authority, from the appearance of such
joints after death, (at least as far as my experience goes,) to sup-
pose this to be the case, or to countenance such opinion. The
cause therefore of this rigidity, which is now and then found to
attend the broken patella, must be sought for elsewhere; vis. in
the long rest and confinement of the joint as a means used by
many to procure exact union; in mischief done to the ligament,
which is formed by the united tendons of the four extensor mus-
cles of the leg, at the time of and by the fracture; and in the na-
the bent posture most advantageous in the broken tibia and femur; viz. the
relaxation of the muscles and tendons attached to the fractured bone.
Whoever will for a moment attend to the disposition of the pieces in a pa-
tella, which has been broken transversely, will see how little" necessary or
useful the many contrivances of bandages, straps, compresses, buckles, but-
tons, &c. to be found in writers are, especially all that part of them which are
applied to the inferior fragment.
By the action of the united tendons of the extensores muscles of the leg,
the superior fragment is pulled upward and separated from the inferior, but
the latter remains nearly, if not absolutely, where it was before the accident;
there is nothing to act upon it, and therefore it cannot, nor does it move.
The extension of the leg puts the muscles attached to the upper part of
the broken bone into a state of relaxation, and prevents their acting ; and
though a small compress just above this piece, with a moderate bandage, may
be useful toward retaining it, yet it is the position of the leg which mu^
keep the broken piece down, and effect the cure.
AND DISLOCATIONS. 251
ture of the fracture itself, that is, the manner in which the bone
shall happen to be broken.
But, be all this as it may, the fact undoubtedly is, that they
walk best after such accident, whose patella has been broken
transversely, and that into two nearly equal fragments; whose con-
finement to the bed has been short, that is, no longer than while
the inflammation lasted; whose knee, after such period, has been
daily and moderately moved; and in whom the broken pieces are
not brought into exact contact, but lie at some small distance from
, each other.'
' It has been sutjgestecl to me that there is an obscurity in this passage^ and
that Mr. Potl's doctrine wllli regard to the fractured patella is not clearly
understood; in consequence of vvliich, his authority has been quoted for
giving motion to the joint soon after the accident, and for keepingthe divid-
ed parts of the patella separate from each other to a great distance.
Whoever has conceived this to be Mr. Pott's meanings has certainly been
mistaken, as his practice differed very materially from it. As the passage
inenlions, that the confinetnent need not be longer than while the inflamma-
tion lasts, the time which is proposed to keep the limb quiet after the acci-
dent is perhaps not sufficiently definite, nor expressed with Mr. Pott's usual
precision, as frequently only a small degree of inflammation is excited, par-
ticularly in those cases where the knee does not reach the ground, which
often happens. Every one conversant in business must have seen instances
of this fact, where the bone is torn asunder by the mere force of the exten-
sor muscles: it has happened to a person standing firm, and reaching for
something on a higli shelf, by which posture those muscles are put into
strong action, as must be evident to any one who will make the experiment;
in these cases there is no external injury, and frequently little inflammation
follows the fracture. Are we then imijiediately to move the limb, and keep
the parts of the bone separate.' Certainly not. Mr. Pott only meant to
caution against too strict and too long confinement; and his constant practice
was, to lay the leg in a perfectly straight posture, to elevate the heel, and,
by a moderate bandage and compress, to bring down the superior portion of
the patella. In this position he usually kept it near thi'ee weeks, after
which time he allowed of a small degree of motion, which he recommended
to be gradually increased.
In fractures of this bone, it is not always in our power to bring the divided
parts into contact, consequently there will be a space, which will be supplied
with ligamentous substance, as the osseous fibres are here sparingly produced.
In proportion to the distance between the two parts of the bone, the chord or
tendon on which the extensor muscles act, must be longer than when the bone
is in its perfect state, and the muscular power must be propt)rtionally lessen-
ed. This should certainly be avoided as much as possible, and can only be
;262 REMARKS ON FRACTURES
1 cannot take leave of this subject of simple fractures, without
nieptioning a circumstance relative to them, which although,
when rightly understood, is of little or no importance, yet, by
being misunderstood, becomes frequently of considerable conse-
quence.
I mean, the use of the term, rising end of a broken bone.
By the expression, any one unacquainted with these things
would be inclined to think, that the prominent part of a broken
bone rose, or was elevated from its natural place; and became by
such rising superior to the other part or extremity of the fracture.
This would certainly be the idea of an ignorant person, and as
such would be of liltle consequence; but by the practice of many,
who call themselves surgeons, it is as certainly their idea also,
and this renders it a matter of great consequence. Many in-
stances are producible, in which our conduct is in great measure
regulated by the language which we use. Having no ideas annexed
to our words, leads us into absurdity and unintelligibility; but
false ones influence us still more, and frequently produce very ma-
terial errors.
The fistula lachrymalis, the fistula in perineo, and that in ano,
are glaring proofs of this; and my present subject is full as much
so: for upon the erroneous idea annexed to the term rising end,
stands all the absurd practice of compress, bolster, and strict ban-
dage in the cases of simple fracture.u
avoided by bringing the parts as nearly as may be into contact. Unless this
union be in some degree preserved, the muscles will have too little power
on the ligament which is inserted in the tibia, althouj'h they contract to the
greatest possible degree; consequently, the person, whose patella is much
elongated, is obliged to depend principally on the flexor muscles of the thigh
and the weight of the leg itself, to bring it forward in progressioti, which is
performed in a most awkward manner, and is found pai-ticularly inconvenient
in going up and down stairs. If both patelisc have been broken, and are in
the same lengthened state, the person is generally obliged to ascend and
descend sideways. E.
" I was some few years ago carried by a surgeon, since dead, to see a con-
trivance of his own to keep down the rising end of a broken tibia. It was
somewhat upon the principle of Petit's tourniquet, and calculated to act by
compression. I told him my opinion freely, but the inventor was wedded to
his invention; and the first simple fracture he applied it to he thereby con-
verted into a compound one, by pressing the bone through the skin.
AND DISLOCATIONS. 253
The truth is, that there is really no rising end to a broken bone;
I mean, when applied, as the term usually is, to the leg, thigh, and
clavicle. There is indeed a superior or prominent end or part,
and an inferior or depressed one; but the former of these is in its
proper place, from which it cannot by art be moved; and the
latter, which is not in its proper place, is very capable by art of
being put into it.
Perhaps this may to some appear a mere play of words, a
nominal distinction, without real difference; but when the influence
which a right or wrong idea of this produces on practice is attend-
ed to, the consequence will be obvious and serious.
When a collar bone, os femoris, or tibia and fibula are broken,
by the action of the muscles, by the motions of the patient, and by
the mere weight of the inferior part of the arm, thigh, or leg, the
fractured ends of such bones are displaced, and always displaced
in such manner, that the inequality occasioRed necessarily by such
displacement, proceeds from the inferior end of the fractured bone
being retracted or drawn under the superior: this produces a
tumefaction or unequal rising; and the upper extremity of the
fracture is therefore called the rising end of it. Now the man
who regards this rising end as that part of the fracture which has
by such rising got out of its place, and not as having accidentally
become the prominent part merely by the insinuation or retraction
of the other part underneath it, will go to work with bolster,
compress, and bandage, in order to bring and keep such end
down; by which means he will give his patient considerable pain,
and, while he depends on such means alone, will most certainly
be frustrated in his intention and expectation, the means not
being adequate to the proposed end. But the man who looks on
this in the true light, that is, who looks on the superior part as
being in its proper place, and the inferior as being displaced by
the weight of the limb and the action of the muscles, will know,
that, by the mere position of such limb, he shall be able to remedy
all the inconvenience and deformity, as far as they are by art
capable of remedy, without the parade or the fatigue of useless
apparatus.
He will, for example, know that the prominent part of a bro-
ken clavicle, that part of it which is next to the sternum, is just
2M REMARKS ON FRACTURES
where it should be; and that the inferior part, that which is con-
nected with the scapula, is out of its place, by being drawn down
by the weight of the arm; and, therefore, instead of loading, as is
usual, the prominent part with quantities of compress, which
never can do any service, he, by a proper elevation of the arm,
will bring the lower end upward into contact with the other; and
thereby, with very little trouble, easily accomplish what he never
can do in any other manner, however operose.
The same thing will happen, from the same principles, in the
leg and thigh: a prominence, or a rising end, there always will
be; but that rising end is never to be brought down by any press-
ure from compress or bandage: the fallen or inferior one must
always be brought up to it by the proper position of the rest of
the limb: this will always remove the inequality as far as it is re-
moveable, and nothing else can."
s In a professed regular treatise on this subject, it would be right to take
notice of what may be called the infortunia or accidental evils, which some-
times accompany even simple fractures ; such are, disease arising from in-
jury done to the medullary membrane, within the bones, in bad habits ; he-
morrhage, or a species of spurious aneurism, from a wound of the interoseal
artery, between tlie tibia and fibula, or of either of the carpal ai-teries; mis-
chief from the fracture becoming accidentally the seat of the crisis of a fe-
ver; deficiency of callus, or the accident of the broken bone not uniting; the
ft-actured limb becoming the seat of an erysipelas, terminating in a slough of
the common membrane and periosteum ; the gelatinous juice or callus, which
should unite the fracture, being in so morbid a state as to produce a kind of
caries with exostosis, instead of doing its proper duty, &c. Of all these there
are examples, but they do not come within the plan which I prescribed to
myself when I began these papers.
AND DISLOCATIONS. 25fi
\* Mr. Pott might undoubtedly have been more diffuise, and
have considerably dilated on his subject, if he had taken into con-
sideration the various incidents which he has enumerated in the
preceding note; and which are sometimes the consequences of
fractured bones: but though (as he observes) this may not be
deemed a professed regular treatise, he has certainly undervalued
it, when he entitled it " A few general Remarks on Fractures and
Dislocations," as the reader must have observed that it abounds
in observations and rules of great consequence on this very im-
portant subject. Andj indeed, it has been the principal cause of
introducing a new mode of treating fractures, which is now almost
universally approved and adopted. The idea of relaxing the mus-
cles, in order more easily to set a broken or dislocated limb, is of
infinite importance; and was certainly not sufficiently attended to
before this treatise made its appearance.
If it were necessary to add any thing to the advantages which
Mr. Pott has mentioned arising from the relaxed position in frac-
tures, it might be observed, that in this situation patients very
rarely suffer from cramps and spasms, which are frequently at-
tendant when the limb is laid straight, and are extremely painful
and productive of mischief; and I might add, that people, whose
limbs have been fractured by a fall, a kick of a horse, or any
other accident, are very subject to such agitation of mind that
their sleep for many nights is unsound; they continually dream of
what they have suffered, and they catch and spring with an ima-
ginary attempt to save themselves. When the leg was laid in a
line with the body, the jerk was infallibly communicated to the
fractured part, which gave the patient excruciating pain, and de-
stroyed his repose for the remainder of the night; and in the morn-
ing the tedious painful process of putting it to rights was neces-
sarily renewed. The involuntary actions of coughing. and sneez-
ing had also the same mischievous effect; and whoever has seen
fractured legs lying in the straight posture must be sensible that
these circumstances have frequently occurred. In the relaxed
position the shock is lost in the bended joints of the hip and knee,
and the limb is not obliged to move with the body. Yet, although
256 REftlARKS ON FRACTURES
I have reason to approve in general of Mr. Potl's plan, of placing
fractured legs on the outside, on the fibula, we sometimes find
cases which should form exceptions to this general rule, particu-
larly in fractures of the leg, where the broken end of the superior
part of the tibia projects forward. In that case we sometimes
find it impracticable to keep the ends of the bone even, without
placing it on the heel.
In compound fractures, also, we sometimes find great advan-
tage in placing the leg on the calf and heel; for instance, where
there is a deep wound leading down to the bone on the inside of
the leg or ancle, if it lies on the outside it is evident that a cavity
must be formed in which the matter will be retained; and which,
being in continual contact with the bones, must create great mis-
chief, as it can only be wiped away, and that very imperfectly,
once or twice a day, when the wound is dressed. In this case,
sometimes by placing the leg on the heel, an effectual current may
be given to the matter, so soon as it is formed; the good effect of
which on the wound will soon be perceived. In short, in all those
cases where there are wounds, in which a depending opening can
be effected by the position on the heel, it is to be preferred.
Except in such and similar cases to those just mentioned, I am
a strong advocate for placing brokenlegs on the outside.
But I must confess that I have long entertained doubts whether
this ought to be considered the best position for broken thighs.
From the large mass of strong muscles surrounding the bone, from
there being only one point of solid contact, and no other bone to
assist in keeping it steady, the thigh-bone is the most difficult to
be placed, and most easy to be displaced, of any in the human
frame. From long experience, I am convinced that bending the
thigh and laying it on the outside, will not insure a straight and
even union; and I appeal to those who have seen many fractured
thighs treated in this manner, if the broken ends of the bone do
not frequently ride over each other, in consequence of which the
broken thigh is often made shorter than the other, and the foot in
walking turns outward. These defects, if they are not very wrong,
become palliated, and less discernible, from the person being ac-
customed to meet them, by lowering, as he walks, the pelvis on
the defective side. But the fact is as I have stated, and has often
AND DISLOCATIONS. ^6t
raised in my mind great objections to placing fractured thighs on
the outside. I conceive that the displacement of the bones in this
case is often owing to the weight of the pelvis bearing down the
superior part of the broken thigh into a depression in the bed; for
if this should give way, and become hollow, the whole of the
thigh, as far as the fractured part, will be carried down and sink
into it, while the lower end of the bone and knee retaining the
first position in which they were placed, an obtuse angle will be
formed; as it is impossible to keep on bandages and splints so
tight as to counteract a deviation from the right position, when ef-
fected by such powerful means. In this case, very able surgeons,
to my knowledge, have been and may again be deceived; for if
the bandage be undone, and the thigh viewed in this position, the
outline of the upper part of the thigh down to the knee will be
perfect, and it will appear straight: but there is often a protrusion
of the upper end of the fracture internally, which is not visible,
and which nothing but accurate examination with the fingers can,
through that vast thickness of soft parts, discover. If it be not
noticed in time, (that is, very early after the accident, perhaps
within a week or ten days, according to the uniting disposition,
which varies in different subjects and from different causes,) the
discovery will be made too late; an adhesion will soon take place
between the ends of the bones and the contiguous muscles; bony
matter will soon be formed in the interspace; and it will not be in
our power to remedy this effect: of course the leg and foot will in
future turn outwards. These considerations have led me, con-
trary to my education, to prefer laying broken thighs in a line
with the body, conceiving that in this situation the fracture is less
liable to be displaced, and that any deviation from the straight
line, whether above or below, or on either side, is more readily
discernible and more easily rectified. I do not wish to insinuate
that placing fractured thighs in the straight position is a new idea.
I know it has been, and is now, practised by many — I only mean
to say, that, though I have long been accustomed to see them laid
in a bent posture, for the reasons above given I prefer the other:
at the same time, in case of laying fractures either of the leg or
thigh in a straight position, we need not lose sight of Mr, Pott'a
first and great principle, the benefit and use of relaxing the mus-
voL. r. K k
258 REMARKS ON FRACTURES
cles; and hj raising the thigh toward the body, supporting that
with pillows, and bending the knee to a certain degree, the same
end may be obtained.
There is one case where we can have no choice — I mean when
both thighs are broken. Under these circumstances it is evident
that the patient must lie on his back, and consequently the thighs
must be in a straight position: when thus of necessity place'd, they
do well; and this is a strong argument in favour of the practice.
But if there be any doubt of superiority between the straight
and bent position of fractured thighs, there is a new contrivance
which I conceive must turn the scale in favour of the former, as in
that posture, the introduction of any kind of machine under the
patient to relieve him from natural evacuations, and the efforts to
raise and assist himself, which from an innate sense of cleanliness
he would otherwise almost involuntarily make, are by that invention
wholly avoided; and! am sure every gentleman of the faculty will
agree with me, that those circumstances are very often the cause
of disturbing and displacing fractured thigh-bones, in whatever
situation they may be placed.
The contrivance consists in a double bed: the upper one has an
opening in the sacking, in a suitable place, and of a proper size,
to which a thin mattress, blanket, and sheet, are made to corre-
spond, with a similar aperture: this, by a very simple piece of
mechanism, may be elevated to a sufficient height for the nurse to
introduce a proper receptacle between that and the fixed bed. The
patient being relieved, the bed is gently let down again upon the
under one, a thin cushion being placed on the under bed, to fill up
the opening and make the upper bed level.
Such a machine has been long and much wanted on many occa-
sions. Indeed it is surprising, that among so many inventions to
promote gratification and convenience, so little has been done for
the accommodation of the bed-ridden, or persons who are unable,
from various causes, to leave their beds. These unfortunate be-
ings, in this age of ingenuity and science, are still left in the same
state that they have been obliged to submit to for centuries past.
It is well known that the common method of refreshing beds
under sick persons is by removing the patient to one sideof tiie
bed, while the other side is shaken up; after which he is again
f
AND DISLOCATIONS. 259
removed till the opposite side is made. This must be allowed to
be only a sort of half-comfort; the bed can be but imperfectly
made, and can have no opportunity of becoming cool; consequent-
ly the patient is again consigned to the annoyance of his own heat
and perspiration; and infractures, rheumatism, gout, and many other
cases which might be mentioned, even this refreshment it is some-
times impossible to give. By this contrivance, the upper bed may
be raised, and the under one completely made, as often as may be
thought necessary or agreeable, without disturbing or discomposing
the patient.
If it be objected, that though the under bed may be made, the
upper one cannot be changed, it may be answered, that the under
one is of the most consequence, being the same feather-bed or
mattresses the person is accustomed to lie on, while the upper one
has only a thin mattress, blanket, and sheet; but by means of a
bar which was added for this and other purposes, it will be found
that the upper bed may also at any time be occasionally changed.
After many years experience of the distressful situation of per-
sons who from various complaints could not be removed from their
loathsome beds, but have been obliged to remain in them till the
very bed and sacking have rotted under them — after having so of-
ten witnessed the difficulty, danger, and not unfrequently the inju-
ry, which is caused by forcing a bed-pan under a patient in cases
of fractures, painful wounds, rheumatic or gouty affections, and
many other instances which might be mentioned — after having
seen many cases in which it was absolutely impossible to intro-
duce it at all, or its more filthy substitute (a draw-sheet), when
the nurse could use no other than the most disgusting and imper-
fect means of cleaning the patient — it cannot be wondered at if
I feel great pleasure in communicating a contrivance, which will
gently raise the patient, permit the bed to be fresh made, and give
him the exquisite delight of coolness and cleanliness.
It is then my opinion, that not only in fractures and dislocations
of the lower limbs, both simple and compound, but in diseases of
the knee, hip, hlid spine; in fevers, when from long continued and
unvaried position, added to moisture and heat, excoriations and
often extensive mortifications take place on the nates, hips, and
lower part of the back; in fistulas in perineo; in the gout and
260 REMARKS ON FRACTURES, &.C.
rheumvitism, in which the least motion is often torture; in the na-
tural confluent small-pox; in child-bearing, particularly in those
cases where puerperal inflammation or clanger of flooding requires
a strict horizontal posture; in cases of insanity, when coercion is
necessary; in sickness, weakness from age, or any other infirmity,
w':iich prevents persons from leaving their beds, or from moving or
being moved in them, the double bed will be found of admirable
use and assistance.
It was invented by Mr. Henry Earle at a very early age, and
soon after the commencement of his professional studies. Inde-
pendent of any partiality, which on that score I might conceive
for the invention, it appeared to me, and indeed is allowed by
every one who has seen it, so well calculated to be useful on a
great variety of occasions, that I have been induced to treat on it
more at large in a Letter; from which this is an extract, and in
which its many comforts and utilities are pointed out.
Representations of the bed will also there be found; and con-
ceiving they would not be unacceptable or unuseful, I have inserted
them in this work. E.
* Containing some ' Observations on Fractures of the Lower Limbs. To
which is added, an Account of a Contrivance to administer Cleanliness and
Comfort to the Bed-ridden, or Persons confined to Eed by Age, Accidents^
Sickness, or any other Infirmity. With Explanatory Plates. E.
'262 REMARKS ON FRACTURES, &C.
PLATE I.
Represents the original bed at St. Bartholomew's hospital, 3 ieet6 inches
wide by 6 feet 4 inches in length. This being made expressly for the pur-
pose, the upper bed corresponds exactly, and fits in with the other ; but
being intended for public and constant use, it is heavier and stronger tlian
is necessary for private families.
Fig. 1, shows the upper bed lying on the under one.
Fig. 2, the upper bed raised to a convenient height.
364 REMARKS ON FRACTURES, &C.
PLATE 11.
Shows the improved plan, in which the upper bed is made of sufficient
width for one person, but it is intended to be placed oh and fixed to any bed
of any breadth.
The upper bed is seen lying on the lower bed, — and also as it appears
when raised up.
Specimens of the bed ma}' be seen at Mr. Oakley'?, No. 8, Old Bond Street,
who has undertaken the manufacture of them.
J^LATJi 1
JPl,^4.TE Z
A'/7V/7 / Focyc 2f2 or 'Zfi-f Vol. 1
AND DISLOCATIONS. 263
COMPOUND FRACTURES.
I USE the term compound fracture in the sense in which the
English have always used it; that is, to imply a broken bone
complicated with a wound.
In this kind of case the first object of consideration is,
whether the preservation of the fiacrured limb can, with
safety to the patient's life, be attempted; or, in other words,
whether the probable chance of destruction, from the nature
and circumstances of the accident, is not greater than it
would be from the operation of amputation. Many things may
occur to make this the case. The bone or bones being broken
into many dilTerent pieces, and that for a considerable extent, as
happens from broad wheels, or other heavy bodies of large surface,
passing over, or falling on such limbs; the skin, muscles, tendons,
&c". being so torn, lacerated, and destroyed, as to render gangrene
and mortification the most probable and most immediate conse-
quence; the extremities of the bones forming a joint being crushed,
or as it were comminuted; and the ligaments connecting such
bones being torn and spoiled; are, among others, sufficient reasons
for proposing and for performing immediate amputation — reasons,
which (notwithstanding any thing that may have been said to the
contrary) long and reiterated experience has approved, and which
are vindicable upon every principle of humanity or chirurgic
knowledge.
When a surgeon says, that a limb, which has just suffered a
particular kind of compound fracture, ought rather to be imme-
diately cut off, than that any attempt should be made for its pre-
servation, he does not mean, by so saying, that it is absolutely im-
possible for such limb to be preserved at all events; he is not to
be supposed to mean so much in general, though sometimes even
that will be obvious; all that he can truly and justly mean is, that
from the experience of all time it has been found, that the attempts
to preserve limbs so circumstanced, have most frequently been
frustrated by the death of the patients, in consequence of such
injury; and that from the same experience it has been found, that
VOL. I. L I
266 REMARKS ON FRACTURES
the chance of death from amputation is by no means equal to that
arising from such kind of fracture.
Every man knows, that apparently desperate cases are some-
times cured; and that limbs so shattered and wounded, as to render
amputation the only probable means for the preservation of life,
are now and then saved. This is an uncontroverted fact, but a
fact which proves very little against the common opinion; because
every man of experience also knows, that such escapes are very
rare, much too rare to admit of being made precedents, and that the
majority of such attempts fail.y
This consideration relative to amputation is of the more import-
ance, because it most frequently requires immediate determina-
tion; every minute of delay is, in many instances, to the patient's
disadvantage; and a very short space of time indeed frequently
makes all the difference between probable safety and fatality. If
these cases in general would admit of deliberation for two or three
days, and during that time such circumstances might be expected
to arise, as ought necessarily to determine the surgeon in his con-
duct without adding to the patient's hazard, the difference would
be considerable; the former would not seem to be so precipitate
in his determination, as he is frequently thought to be; and the
y The baron Van Swieten, writing, as many others have done, that is,
theoretically, on surgery, advises us, in tlie case of very bad compound frac-
tures, which may most probahly require amputation, to defer the operation,
until we have tried the force of antiseptic fomentation and applications of
like kind for two or three days ; and this opinion and advice he builrls, in
some meaaure, on a remarkable success of La Motte, in a seemingly despe-
rate case, of li man's leg mashed by the wheel of a heavy carriage.
That De La Motte's patient esc:)ped, I make no doubt, because he has
said SO; but the surgeon showed much more rashness in attempting to save
such a limb, than he would liave done in the amputation of it : the operation
would have been the more justifiable practice. With regard to the baron's
advice, to stay two or three days, I take the liberty to add, that if you do that,
stay several more ; for at the end of that time (I mean two or three days)
the patient will have very little chance indeed from the operation, much less
, than lie would have had at the time of tlie accident.
I should be very sorry to be Uiouglit a patron or an adviser of rashness or
cruelty ; but in what I have he.iv. said, I believe 1 shall have every man in (he
profession, who lias either true ihumanity or sound judgment, founded on ex-
perience, on my side.
AND DISLOCATIONS. 267
latter, being more convinced of the necessity, would submit to it
with less reluctance. But unhappily for both parties, this is seldom
the case; and the first opportunity having been neglected or not
embraced, we are very frequently denied another. Here there*
fore the whole exertion of a mans judgment is required, that he
may neither rashly and unnecessarily deprive his patient of a limb,
nor, through a false tenderness and timidity, suffer him to perish
by endeavouring to preserve such limb. Some degree of address
is also necessary upon such occasion, in order to convince the
patient, that what seems to be determined upon hastily and with
precipitation, will not safely admit of longer deliberation.*
The limb being thought capable of preservation, the next con-
sideration is the reduction of the fracture. The ease or difficulty
« That there are many cases which, from the extent of the laceration or
from iisemorrhage, particular!} in the leg, where the interosseal artery is torn
by the ragged ends of the bones, and from other circumstances, it may be
necessary to proceed to immediate amputation, must be allowed. But ex-
cept in cases of extreme necessltyj I must say, that sometimes, where the ap-
pearances scarcely furnish the glimmering of a bope of ultimately saving the
limb, if the person appeared of a robust over-full habit, I should be inclined
to wait, and to put off' the operation until inflammation had taken place, and
bad subsided, and the patient had changed the high and boisterous state of
health which he enjoyed at the time of meeting with the accident, for a
quieter or more temperate circulation, when I conceive he would stand a
better chance of recovering from the operation. I will here quote two similar
accidents which terminated very differently : —
A stout lusty man, of a full habit of body, was employed at the European
Museum to hang some pictures. When on the ladder, he fell down with a
heavy picture in liis hands, by which his right foot and ancle were crushed,
and dreadfully mangled. Though there was very little probability of the
limb being saved, it was judged right to attempt it. I did not see him at
first, but afterwards in consultation, when it appeared to me impossible to
preserve the limb ; but as his habit was apparently gi'oss and full, it was
agreed to wait some time longer. The quantity of discharge, low diet, and
proper medicines lowered his constitution to a pitch much inferior to high
health. He was now evidently losing ground ; and as there remained not the
most distant prospect of preserving the limb, it was amputated. Without
any adverse circumstances, he got well, and remains a healthy man.
A gentleman, getting up on a library-ladder, fell down, and received a
very bad compound fracture of the leg : it was judged, in consuliation, im-
possible to save the limb, and immediate amputation took place. Inflammatoiy
symptoms succeeded so high as to cause his death. E,
268 EEMARKS ON FRACTURES
attending this depends not only on the general nature of the case,
but on the particular disposition of the bone with regard to the
wound.
If the bone be not protruded forth, the trouble of reducing, and
of placing the fracture in a good position, will be much less than
if the case be otherwise; and in the case of protrusion or thrusting
forth of the bone or bones, the difficulty is always in proportion to
the comparative size of the wound, through which such bone has
passed. In a compound fracture of the leg or thigh, it is always
the upper part of the broken bone which is thrust forth. If the
fraciure be of the transverse kind, and the wound large, a mode-
rate degree of extension will in general easily reduce it; but if the
fracture be oblique, and terminates, as it often does, in a long
sharp point, this point very often makes its way through a wound
no larger than just to permit such extension. In this the very
placing the leg in a straight position, in order to make extension,
obliges the wound or orifice to gird the bone tight, and makes all
that part of it, which is out of such wound, press hard on the skin
of the leg underneath it. -In these circumstances, all attempts for
reduction in this manner will be found to be impracticable; the
more the leg is stretched out, the tighter the bone will be begirt
by the wound, and the more it will press on the skin underneath.
Upon this occasion, it is not very unusual to have recourse to
the saw, and by that means to remove a portion of the protruded
bone.
I will not say that this is always or absolutely unnecessary or
wrong, but it most certainly is frequently so. In some few in-
stances, and in the case of extreme sharp-pointedness of the ex-
tremity of the bone, it may be, and undoubtedly is right: but in
many instances, it is totally unnecessary.
The two most proper means of overcoming this difficulty are,
change of posture of the limb, and enlargement of the wound. In
many cases the former of these, under proper conduct, will be
found fully sufficient; and where it fails, the latter should always
be made use of. Whoever will attend to the effect, which putting
the leg or thigh (having a compound fracture and protruded bone)
into a straight position always produces; that is, to the manner
in which the wound in such position girds the bone, and to the
AND DISLOCATIONS. 269
increased difficulty of reduction thereby induced, and will then,
by changing the posture of such limb from an extended one, to
one moderately bent, observe the alteration thereby made, in both
the just mentioned circumstances, will be satisfied of the truth of
what I have said, and of the much greater degree of ease and
practicability of reduction in the bent, than in the extended posi-
tion; that is, in the relaxed, than in the stretched state of the mus-
cles. Reduction being found impracticable, either by extension
or change of posture, the obvious and necessary remedy for this
difficulty is enlargement of the wound. This to some practi-
tioners, who have not seen much of this business, appears a dis-
agreeable circumstance, and therefore they endeavour to avoid
it; but their apprehensions are in general groundless and ill-
founded. In enlarging the wound there is neither difficulty nor
danger; it is the skin only which can require division; and in
making such wound there can be no possible hazard. It is need-
less to say that the division should be such as to render reduction
easy; or to remind the practitioner, that such enlarged opening
may serve very good future purposes, by making way for the ex-
traction of fragments, and the discharge of matter, sloughs, &,c.
If the bone be broken into several pieces, and any of them be
either totally separated, so as to lie loose in the wound, or if they
be so loosened and detached as to render their union highly im-
probable, all such pieces ought to be taken away; but they should
be removed with all possible gentleness, without pain, violencCj
or laceration, without the risk of haemorrhage, and with as little
poking into the wound as possible. If the extremities of the bone
be broken into sharp points, which points wound and irritate the
surrounding parts, they must be removed also. But the whole of
this part of the treatment of a compound fracture should be exe-
cuted with great caution; and the practitioner should remember,
that if the parts surrounding the fracture be violated, that is, be
torn, irritaied, and so disturbed as to excite great pain, high in-
flammation, &c. it is exactly the same thing to the patient, and to
the event of the case, whether such violence be the necessary con-
sequence of the fracture, or if his unnecessary and awkward mau-
liier of poking into, and disturbing the wound. The great objects
of fear and apprehension in a compound fracture (that is, in the
270 REMARKS ON FRACTURES
first or early state of it) are, pain, irritation, and inflammation;
these are to be avoided, prevented, and appeased by all possible
means, let every thing else be as it may; and although certain
things are always recited, as necessary to be done, such as remo-
val of fragmen's of bone, of foreign bodies, &c, &c. &c. yet it is
always to be understood, that such acts may be performed with-
out prejudicial or great violence, and without adding at all to the
risk or hazard necessarily incurred by the disease.
■ Reduction of or setting a compound fracture is the same as in
the simple; that is, the intention in both is the same, viz. by means
of a proper degree of extensiQn to obtain as apt a position of the
ends of the fracture with regard to each other, as the nature of the
care will admit, and thereby to produce as perfect and as speedy
onion as possible.
To repeat in this place what has already been said under the
head of extension, would be tedious and unnecessary. If the argu-
ments there used for making extension, with the limb so moderately
bent as to relax the muscles, and take off their power of resistance,
have any force at all, they must have much more when applied
to the present case: if it be allowed to be found very painful to
extend, or to put, or keep on the stretch, muscles which are not
at all or but slightly wounded, and only liable in such extension
to be pricked and irritated, it is self-evident that it must be much
more so when the same parts are torn and wounded considerably;
when the ends of the fractured bone have made their way quite
through them, divided the skin, and laid all open to the access of
the air.
Every consequence which does or may be supposed to flow from
wound, pain or irritation, in consequence of violence, must neces-
sarily be much greater, when a lacerated wound, and that made
by the bone, is added to the fracture; not to mention the ills arising
from extending or stretching out muscles already torn or half
divided.
One moment's reflexion must be sufficient to convince any rea-
sonable man: but experience is the only proper test of all these
kinds of things. Let this method of treatment then be fairly and
properly subjected to it; and if the great advantage of the one over
the other does not appear, that is, if the less sensation of pain by
AND DISLOCATIONS, 271
the patient, and the more huppy, more perfect, and more expedU
tious accomplishment of his purpose by the surgeon, do not deter-
mine greatly in favour of relaxed position, I am, and have, for a
considerable length of time, been greatly misiaken.
The wound dilated, (if necessary,) loose pieces removed, (if
there were any,) and the fracture reduced, and placed in the best
possible position, the next thing to be done is to apply a dressing.
On this subject a great deal has been said by writers, particu-
larly by such of them as have implicit faith in external applica-
tions; but, in order to be able to execute this part of the process
properly, a man has only to ask himself. What are the intentions
which, by any kind of dressing to a compound fracture, he means
to aim at the accomplishment of? And a rational answer to this
will give hiai all thai he can want to know.
The dressing necessary in a compound fracture is of two kinds;
viz. that for the wound, and that for the limb. By the former,
we mean to maintain a proper opening for the easy and free dis-
charge of gleet, sloughs, matter, extraneous bodies, or fragments
of bone, and this in such manner, and by such means, as shall
give ihe least possible pain or fatigue, shall neither irritate by its
qualities, nor oppress by its quantity, nor by any means contribute
to the detention or lodgement of what ought to be discharged. By
the latter, our aim should be the prevention or removal of inflam-
mation, in order, if the habit be good, and all other circumstances
fortunate, that the wound may be healed, by what the surgeons call
the first intention, that is, without suppuration or abscess; or that
not being practicable, that gangrene and mortification, or even
very large suppuration may be prevented, and such a moderate
and kindly degree of it established as may best serve the purpose
of a cure. The first therefore, or the dressing for the wound, can
consist of nothing better, or indeed so good, as soft dry lint, laid
on so lightly as just to absorb the sanies, but neither to distend
the wound, nor be the smallest impediment or obstruction to the
discharge of matter. This lint should be kept clear of the
edges, and the whole of it should be covered with a pledget spread
with a.soft easy digestive. The times of dressing must be deter-
mined by the nature of the case: if the discharge be small or mo-
derate, once in twenty-four hours will be sufficient; but if it be
272 REMARKS ON FRACTURES
large, more frequent dressing will be necessary, as Aveli to pre-
vent offence, as to remedy the inconveniences arising from a great
discharge of an irritating sharp sanies.
The method of treating the limb, with a view to the preven-
tion of such accidents and symptoms, as pain, inflammation, and
laceration of parts, are likely to produce, is different with different
practitioners; some using, from the very first, relaxing, greasy
applications; others applying medicines of very different nature.
Both these may be right conditionally, that is, according to dif-
ferent circumstances in the cases, but they cannot be equally
so in the same circumstances.
Many practitioners are accustomed to envelope compound frac-
tures in a soft, warm, relaxing cataplasm from the very first;
whether the limb be in a tense swollen state, or not. This, if I
may take the liberty of saying so, appears to me to be injudicious.
When from neglect, from length of time passed without assist-
ance, from misconduct or drunkenness in the patient, from awk-
wardness and unhandiness in the assistants, or from any other
cause, a tension has taken possession of the limb, and it is be-
come tumid, swollen, and painful, a warm cataplasm is certainly
the best and most proper application that can be made, and that
for very obvious reasons: the state of the parts under these cir-
cumstances is such, that immediate union is impossible, and no-
thing but a free and plentiful suppuration can dissipate or remove
impending mischief: every thing therefore which can tend toward
relaxing the tense, swollen, and irritable state of the parts con-
cerned, must necessarily be right; the one thing aimed at (plenti-
ful suppuration) cannot be accomplished without it. But when
the parts are not in this state, the intention seems to be very dif-
ferent. To relax swollen parts, and to appease pain and irrita-
tion by such relaxation, is one thing; to prevent inflammatory de-
fluxion and tumefaction is certainly another; and they ought to be
aimed at by very different means. In the former a large suppura-
tion is a necessary circumstance of relief, and the great means of
cure; in the latter it is not, and a very moderate degree of it is all
that is required. The warm cataplasm, therefore, although it be
the best application that can be made use of in the one case, is
AND DISLOCATIONS. 273
certainly not so proper in the other, as applications of a more dis-
cutient kind, such as mixtures of spirit, vini., vinegar and water,
with crude sal ammoniac, spirit, mindereri, acet. litharg., and
medicines of this class, in whatever form the surgeon may choose.
By these, in good habits, in fortunately circumstanced cases, and
with the assistance of what should never be neglected, I mean
phlebotomy, and the general antiphlogistic regimen, inflammation
may sometimes be kept off, and a cure accomplished, without
large collections or discharges of matter, or that considerable de-
gree of suppuration, which, though necessary in some cases, and
almost unavoidable in others, are and must be rather promoted
and encouraged than retarded or prevented, by warm relaxing ap-
plications of the poultice kind.*
* The principal cause of the inflammation, and the consequent bad symp-
toms which so frequently take place in compound fructures, appears to arise
from the admission of air into the wound among the fractured bones; for we see
that bones may be broken, ligaments and tendons may be bruised, torn, and
wounded in any manner, and will unite, heal, and do well again, like other
soft parts, provided no air gains admission : but if that is suffered to enter, it
too often lights a fire which the art of surgery cannot quench. The stimu-
lating influence of air on diseased cavities, is evident on many occasions. In
the psoas abscess, matter may be formed and increased, so as to make a swell-
ing of great magnitude ; the patient will notwithstanding continwe free from
fever : but from the moment it is opened, and air admitted, a hectic fever
takes place. Large extravasations of blcod will remain in a quiet state for
any length of time till they are re-absorbed, provided the skin remains whole ;
but if an opening is made, and air permitted to enter, a stimulus is applied,
inflammation is excited, ai>d a putrid slough of the sides of the cavity and its
contents will generally be the consequence. Many other instances might be
adduced, to prove that air, from whatever principle it acts, is certainly the
great enemy in all these cases. Our first aim should therefore be to prevent
it from entering, or, if it has entered, to exclude it; and this may frequently
be accomplished by closing the wound as soon as possible, after the bones are
placed in their proper situation, and by keeping it close with slips of sticking
plaster; or in some cases sutures may be employed with advantage : it should
then be covered with proper dressings, such as dry lint and sedative applica-
tions, avoiding every thing greasy. These first dressings should not be re-
moved for many days, unless a collection of matter makes it necessary to
change them. By these means the wounds in the soft parts may often be
biought to heal by the first intention ; and thus compound fractures, unat-
tended with the usual long train of evils which Mr. Pott has so well described,
will frequently unite, and give no more trouble than simple fractures. The
fortunate termination of the compound fracture in his own leg, was proba-
VOL. I. M m
Uli REMARKS ON FRACTURES
Compound fractures in general require to be dressed every day;
and the wounded parts not admitting the smallest degree of motioa
without great pain, perfect quietude becomes as necessary as fre-
quent dressing.
bly owing' to the air being excluded: but t!iis arose from tlie naUire of tl\e
fracture, rather than from the manner in whicli it was treated, as the idea of
preventing the first admission of air, in these c;ises, was not at th.it time at-
tended to; though, while they were clianging tiieir dressings, by means of
lamps and other contrivances, our forefathers endeavoured to correct its per-
nicious effects, which they ascribed to cold. In Mr. Pott's case, the fact was,
that the bone had made its way through the skin at a distance from tlie frac-
ture; so that, when it was returned into its place, the soft parts closed, and
prevented the air from getting in ; by which means the wound healed by
the first intention. I have now under my care a man who had a compound
fracture of the leg. The wound was small, easily closed, and kept so by
sticking plaster: as no bad symptoms followed, the first dressings were suf-
fered to remain a fortnight, at the end of which time the wound was found
healed, and the bones firm. Had it not been thus treated — on the contrary,
had the dressings been removed, and the air suffered to enter — it is more
than probable that the usual bad symptoms would have arisen; for the dan-
ger in compound fractures does not depend on the size of the wound. If air
gets in, a small wound is equally bad as a large one, perhaps worse, by con-
fining the matter after it is collected. I have mentioned this case as it occurs
on the instant ; but could adduce many more, in which equal success has at-
tended this mode of practice.
The benefit arising from keeping out air, in these cases, was an observa-
tion I made when very young in the profession ; and practice and experience
have convinced me of the truth of it. I was sent tor, many years ago, to a
person who by a fall had a compound dislocation of the joint of the ancle.
The skin was torn evenly, as if it had been divided with a knife : I could
pass my finger into the cavity of the joint. Being aware of the horrid mis-
chief which is usually produced by air being admitted into tliesc cavities, I
was induced to try what would be the consequences of its entire exclusion:
accordingly I sewed up the wound close, with a number of fine stitches, mere-
ly passing them through the edges of the skin, and then applied proper dress-
ing and bandage. The wound, to my great surprise, healed by the first inten-
tion, without more inflammation than usually attends wounds of any other part.
It may be proper to remark, that at the same time the man had received so
violent a contusion on his back as to render his lower limbs paralytic. How far
the want of nervous influence might have been the cause of the small degree
of inflammation which took place, I cannot determine. It is a case which
will not be easily paralleled, and no one can suppose that I mean to say that
this plan will always succeed in compound fractures. However, the attempt
is worth making in most cases, as no detriment can arise from it ; and if we
gain our point, it is a most important one to the patient, who avoids a tedious
AND DISLOCATIONS. 2T5
The common bandage therefore (the roller) has always in this
case been laiu aside, ami what is called the eighteen-tailcd ban-
dage substituted, very judicicuslj, in its place. Of (his I have
already spoken so largely, as to make repetition unnecessar3\
Splints, that is, such short ones as are most commonly made use
©f in simple fractures, are by all forbid in the compound, and that
for the same reason which ought to have prevented tnem from
having ever been used in the former; viz. because t.;e probable
good to be derived from them can be but little; and the probable
mischief is obvious and considerable.
But although short splints are for many reasons palpably im-
proper, in both cases, yet those of proper length, those which
reach from joint to joint, comprehend them both, and are applied
on each side of the leg only, are very useful both in the simple
and in the compound fracture; as they may, thus applied, be made
to keep the limb more constantly steady and quiet, than it can be
kept without them.
With regard to position of the limb, I have already been so
explicit, when speaking of the simple fracture, that to say any
thing more about it here would be an- abuse of the reader's
time and patience. The only, or the material difference between
a simple and a compound fracture, as far as relates to this part
of the treatment, is, that as the parts surrounding the broken bone
in the latter are more injured, and consequently more liable to
irritation, pain, inflammation, and all their consequences, there-
fore every method and means, by which the alleviation of such
symptoms, and the prevention of such consequences can be ob-
tained, is still more necessary and requisite. Among these the
posture of the' limb is so principal a circumstance, that without
its concurrence every other will be fruitless. The points to be
aimed at are, the even position of the broken parts of the bone,
and such disposition of the muscles surrounding thepi, as is most
suitable to their wounded, laceratied state, as shall be least likely
confinement of perhaps man)'- months, not to mention all the concomitant
evils. During this healing process we should endeavour to prevent inflam-
mation from taking place by sedative applications, of which the saturnine are
most efficacious ; and by every meanSj both internal ^vd external, which ex-
perience suggests, K
376 REMARKS ON FRACTURES
to irritate them, by keeping them on the stretch, or to produce
high inflammation, and at best large suppuration. These, I say,
are the ends to be pursued; and how much the position of the limb
does, and must necessarily contribute to the advantage or disad-
vantage just recited, must be so obvious to any body capable of
reflexion, that nothing more need be said about it.
At the beginning of these sheets, I have said, that it was not
my intention to write a regular treatise, but only to throw out a
few hints which I hoped might prove useful to such as have not
yet received better information. The part of my subject at which
I am now arrived, does not indeed admit of much more: a few
general precepts are all which a writer can give: the particular
method of conducting each particular case must be determined by
the nature of that case, and by the judgment of the surgeon.
Every body knows, or ought to know, that these cases of all
others require at first the most rigid observance of the antiphlo-
gistic regimen; that pain is to be appeased, and rest obtained, by
anodynes; that inflammation is to be prevented or removed by free
and frequent bleeding, by keeping the body open, and by the ad-
ministration of such medicines as are best known to serve such
purposes; and that, during this first state or stage, the treatment
of the limb must be calculated, either for the prevention of inflam-
matory tumefaction, by such applications as are in general known
by the title of discutients; or, such tumor and tension having
already taken possession of the limb, that warm fomentation and
relaxing and emollient medicines are required.
If these, according to the particular exigence of the case, prove
successful, the consequence is, either a quiet easy wound, which
suppurates very moderately, and gives little or no trouble; or a
wound, attended at first with considerable inflammation, and that
producing large suppuration, with great discharge and troublesome
formation and lodgement of matter. If, on the other hand, our
attempts do not succeed, the consequence is gangrene and mor-
tification.
These are three general events or terminations of a compound
fracture, and according to these must the surgeon's conduct be
. regulated.
AND DISLOCATIONS. 277
In Ihe first instance, he has indeed nothing to do but to avoid
doing mischief, either by his manner of" dressing, or by disturbing
the limb. Nature let alone will accomplish her own purpose;
and art has little more to do than to preserve the due position of
the limb, and to take care that the dressing applied to the wound
proves no impediment.
In the second stage, that of formation and lodgement of matter,
in consequence of large suppuration, all a surgeon's judgment will
sometimes be required in the treatment both of the patient and his
injured limb. Enlargement of the present wound, for the more
convenient discharge of matter;** new or counter openings for the
same purpose, or for the extraction of fragments of broken or ex-
foliated bone, will very frequently be found necessary, and must
be executed. In the doing this, care must be taken that what is
requisite be done, and no more; and that such requisite operations
be performed with as little disturbance and pain as possible: the
manner of doing business of this kind, will make a very material
difference in the sufferings of the patient.
Very contrary, or at least very different intentions, seem to me
to require the surgeon's very particular attention in the two parts
of this stage of the disease.
Previous to large suppuration, or considerable collections and
lodgements of matter, tumefaction, induration, and high inflamma-
tion, attended with pain, irritation, and fever, require evacuation
by phlebotomy, an open belly, and antiphlogistic remedies, as
well as the free use of anodynes, and such applications to the limb
as may most serve the purpose of relaxation. But the matter
having been formed and let out, and the pain, fever, &c., which
were symptomatic thereof, having disappeared or ceased, the use
and purpose of such medicines and such applications cease also,
*> It is a practice with some, from a timidity in using a knife, to make use
of bolsters and plaster-compresses for the discharge of loi'ging matter.
Wliere another or a counter opening can conveniently and safely be made,
it is always preferable, the compress sometimes acting diametrically opposite
to the intention with which it is applierl, and contributing to the lodgement
by confining the matter ; beside which, it requires a greater degree of pres-
sure to make it efficacious, than a limb in such circumstances generally can
bear.
278 REMARKS ON FRACTURES
and they ought therefore to be disconlinued. By evacuation, &c.,
the patient's strength has necessarily (and indeed properly) been
reduced: by cataplasm, &c., the parts have been so relaxed as to
procure an abatement or cessation of inflammation, a subsidence
of tumefaction, and the establishment of a free suppuration; but,
these ends once fairly and fully answered, another intention arises,
which regards the safety and well-doing of the patient, nearly, if
not full as much as the former; which intention will be neces-
sarily frustrated by pursuing the method hitherto followed. The
patient now will require refection and support, as much as he be-
fore stood in need of reduction; and the limb, whose indurated and
inflamed state hitherto required the emollient and relaxing poultice,
will now be hurt by such kind of application, and stand in need
of such as are endued with contrary qualities, or at least such
as shall not continue to relax. Good, light, easily digested nutri-
ment, and the Peruvian bark, will best answer the purpose of in-
ternals: the discontinuation of the cataplasms, and the application
of medicines of the corroborating kind, are as necessary with re-
gard to externals."
In short, if there be any rationale in the use. of the cataplasm in
the first stage, its impropriety in the second must be evident from
the same principles. So also with regard to evacuation, and the
antiphlogistic regimen, when all the good proposed to be obtained
by them has been received, a pursuit of the same method must
become injurious, and that for the same reason which before
rendered it necessary and beneficial.
A non-attention to this has, I believe, been not infrequently the
cause of the loss both of limbs and lives.
Every body who is acquainted with surgery knows, that in the
case of bad compound fracture, attended with large suppuration,
it sometimes happens, even under the best and most judicious
'^ It is suvprising how lar.g'e and how disagrreable a discharge will be m:ide
for a considerable length of time, in some instances, from the detention and
irritation of a splinter of bone. If therefore such discharge be made, and there
be neither sinus nor lodgement to account for it, and all other circumvtances
are favourable, examination should always be made, in order to know whether
.such cause does not exist ; arid if it does, it must be g-ently and carefully
removed.
AND DISLOCATIONS. 279
treatment, that the discharge becomes too great for the patient to
sustain; and that, after all the fatigue, pain, and discipline, which
he has undergone, it becomes necessary to compound for life by
the loss of the limb.** This, I say, does sometimes happen under
the best and most rational treatment; but I am convinced that it
also is now and then the consequence of pursuing the reducing, the
antiphlogistic, and the- relaxing plan too far. I would therefore
take the liberty seriously to advise the young practitioner, to attend
diligently to his patient's pulse and general state, as well as to that
of his fractured limb and wound; and when he finds all febrile
complaint at an end, and all inflammatory tumor and hardness
gone, that his patient is rather languid than feverish, that his pulse
is rather weak and low than hard and full, that his appetite begins
to fail, and that he is inclined to sweat or purge without assignable
cause, and this in consequence of a large discharge of matter from
a limb which has suffered great inflammation, but which is now
become rather soft and flabby than hard and tumid; that he will
in such circumstances set about the support of his patient, and the
strengthening of the diseased limb, totis viribus; in which I am
from experience satisfied, he may often be successful where it may
not be generally expected that he would. At least he will have
the satisfaction of having made a rational attempt; and if he be
obliged at last to have recourse to amputation, he will perform it,
and his patient will submit to it, with less reluctance than if no
such trial had been made.
I have said that a compound fracture either unites and heals as
it were by the first intention, which is the case of some few, (and
was my own,) or it is attended with high inflammation, multiplied
abscesses, and large suppuration, demanding all the surgeon's atten-
tion and skill, and even then sometimes ending in the loss of
limb, or life, or both; or, that all our attempts prove fruitless frona
^ There is one circumstance relative to compound fractures which per-
haps may be deemed worth noting ; wliich is, that I do not remember ever
to have seen it necessary to amputate a limb for a compound fracture, on
account of the too great discharge, in which the fracture had been united.
In all those cases, where the operation has been found necessary on account
■of the drain, the fracture has always been perfectly loose and disunited.
280 REMARKS ON FRACTURES
the first, and gangrene and mortification are the inevitable conse-
quence of the accident.
The two first I have ah-eady spoken to — the last only remains.
Gangrene and mortification are sometimes the inevitable conse-
quences of the mischief done to the limb at the time that the
bone is broken; or they are the consequences of the laceration of
parts made by the mere protrusion of the said bone.
They are also sometimes the effect of improper or negligent
treatment; of great violence used in making extension; of irrita-
tion of the wounded parts, by poking after, or in removing frag-
ments or splinters of bone; of painful dressings; of improper dis-
position of the limb, and of the neglect of phlebotomy, anodynes,
evacuation, &c. Any, or all these, are capable either of inducing
such a state of inflammation as shall end in a gangrene, or of per-
mitting the inflammation, necessarily attendant upon such acci-
dent, to terminate in the same event.
When such accident or such disease is the mere consequence of
the injury done to the limb, or produced by it at the time of frac-
ture, it generally makes its appearance very early; in which case,
also, its progress is generally too rapid for art to check. For these
reasons, when the mischief seems to be of such nature as that
gangrene and mortification are most likely to ensue, no time can
be spared; and the impending mischief must either be submitted
to, or prevented by early amputation. I have already said, that a
very few hours make all the difference between probable safety
and destruction. If we wait till the disease has taken possession
of the limb, even in the smallest degree, the operation will serve
no purpose, but that of accelerating the patient's death. If we wait
for an apparent alteration in the part, we shall have waited until
all opportunity of being really serviceable is past. The disease
takes possession of the cellular membrane surrounding the large
blood-vessels and nerves, some time before it makes any appear*
ance in the integuments; and will always be found to extend
much higher in the former part, than its appearance in the latter
seems to indicate. I have more tha!n once seen the experiment
made of amputating, after a gangrene has been begun, but I never
saw it succeed: it has always hastened the patient's dissolution.
As far therefore as my experience will enable me to judge, or
AND DISLOCATIONS. 281
as I may from thence be permitted to dictate, I would advise that
such attempt should never be made: but the first opportunity
having been neglected or not embraced, all the power of the chi-
rurgic art is to be employed in assisting nature to separate the dis-
eased part from the sound; an attempt which now and I hen, under
particular circumstances, has proved successful, but which is so
rarely so, as not to be much depended upon.
If the parts are so bruised and torn, that the circulation through
them is rendered impracticable, or if the gangrene be the immediate
effect of such mischief, the consequence of omitting amputation,
and of attempting to save the limb, is, as I have already observed,
most frequently very early destruction: but if the gangrenous mis-
chief be not merely and immediately the effect of the wounded
state of the parts, but of high inflammation, badness of general
habit, improper disposition of the limb, &.c., it is sometimes in
our power so to alleviate, correct, and alter these causes, as to ob-
tain a truce with the disease, and a separation of the unsound parts
from the sound. The means whereby to accomplish this end, must,
in the nature of things, be varied according to the producing causes
or circumstances: the sanguine and bilious must be lowered
and emptied; the weak and debilitated must be assisted by such
medicines as will add force to the visvUm; and errors in the treat-
ment of the wound or fracture must be corrected: but it is evident
to common sense, that for these there is no possibility of prescrib-
ing any other than very general rules indeed. The nature and cir-
cumstances of each individual case must determine the practitio-
ner's conduct.
In general, inflammation will require phlebotomy and an open
belly, together with the neutral antiphlogistic medicines; pain and
irritation will stand in need of anodynes and the Peruvian bark, join-
ed in some cases and at some times with those of the cooling kind,
at others with the cordial, will be found necessary and useful. So
also tension and induration will point out the use of fomentation
and warm relaxing cataplasms, and the most soft and lenient treat-
ment and dressing. But there are two parts of the treatment of
this kind of case mentioned by the generality of writers, which I
cannot regard in the same pointof view with then% One is, the
the use of stimulating antiseptic applications to the wound; the
VOL. I. N n
382 REMARKS ON FRACTURES
Other is, what is commonly called scarification of the limb. [Let
it be remarked that I speak of both these, as prescribed and prac-
tised while the gangrene is forming, as it were, and the parts are
by no means mortified.] While the inflammatory tension subsists,
alleviation of pain, and relaxation of the wound and swollen parts,
in order to obtain a suppuration, and conseqnenily a separation,
seem to constitute the intention, which ought to be pursued upon
the most rational principles. Warm irritaling tinctures of
mvrrh, aloes, and euphorbium; mixtures of tinct. myrrh, with
me!. iEgyptiac. and such kind of medicines, which are found to
be frequently ordered, and indeed are frequently used, par-
ticularly in compound fractures produced by gun-shot, seem
to me to be very opposite to such intention, and very little
likely to produce or to contribute to the one thing which ought to
be aimed at, I mean the establishment of a kindly suppuration. I
know what is said in answer to this; viz. that such kind of stimu-
lus assists nature in throwing off the diseased parts: but this is a
kind of language, which I believe will be found upon examination
to have been first used without any sufficient or good ground, and
to have been echoed ever since upon trust. It had its foundation
in the opinion that gun-shot wounds were poisonous, and that the
morlifjcaiion in them was the eiTect of fire, and it has been conti-
nued ever since, to the great detrlaient of many a sufferer. A gun-
shot wound, whe'iher with or without fracture, is a wound accompani-
ed with the highest degree of contusion, and with some degree of
laceration; and every greatly contused and lacerated wound re-
quires the same kind of treatment which a gun-shot wound does,
as far as regards the soft parts. The intention in both ought to be
to appease pain, irritation, and inflammation, to relax the indurat-.
ed, and to unload the swollen parts, and by such means to procure
a kindly suppuration, the consequence of which must be, a sepa-
ration of the diseased parts from the sound. Now whether this is
likely to be best and soonest accomplished by such dressings
and such applications as heat and stimulate, and render the parts
to which they are applied crisp and rigid, may fairly be left to
common sense to determine.
Scarification, in the manner and at the time in which it is gene-
rally ordered and performed, has never appeared to me to have
served any one good purpose. When the parts are realty morti-
fied, incisions made of sufficient depth will give discharge to a
AND DISLOGATIONS. 283
quantity of acrid and offensive ichor; will let out the confined air,
which is the effect of putrefaction, and thereby will contribute to
unloading the whole limb; and they will also make way for the
apj)lica(ion of proper dressings. But while a gangrene is impend-
ing, that is, while the parts are in the highest slate of inflammation,
what the benefit can be which is supposed or expected to proceed
from scratching the surface of the skin with a lancet, J never could
imagine; nor, though I have often seen it practised, do I remem-
ber ever to have seen any real benefit from it. If the skin be
still sound, and of quick sensation, the scratching it in this super-
ficial manner is painful, and adds io the inflamed state of it: if it
be not sound, but quite altered, such superficial incision can do no
possible service. Boih the sanies and the imp''isoned air are be-
neath the membrana adiposa; and merely scratching the skin in
the superficial manner in which it is generally done, will not reach
to, or discharge either.
From what has been said, it will appear, that there are three
points of time, or three stages of a bad compound fracture, in
which amputation of the limb may be necessary and right; and
these three points of time are so limited, that a good deal of the
hazard or safety of the operation depends on the observance or
non-observance of them.
The first is immediately after the accident, before inflammation
has taken possession of the parts. If this opportunity be neglected
or not embraced, the consequence is either a gangrene or a large
suppuration, with formation and lodgement of matter. If the former
of these be the case, the operation ought never to be thought of, till
there is a perfect and absolute separation of the mortified parts.
If the latter, no man can possibly propose the removal of a limb,
until it be found, by sufficient trial, that there is no prospect of
obtaining a cure without, and that, by not performing the opera-
lion, the patient's strength and life will be exhausted by the dis-
charge. When this becomes the hazard, the sooner amputation
is performed the better. In the first instance, the operation ought
to take place before inflammatory mischief is incurred; in the se-
cond, we are to wait for a kind of crisis of such inflammation; in
the third, the proportional strength and state of the patieni, com-
pared with the discharge and state of the fracture, must form our
determination.
284 REMARKS ON FRACTURES
*^* In my account of the double bed, which is mentioned in »
preceding note, it will be found that it not only is conducive to
cleanliness and health, but that it affords great relief to both pa-
tient and surgeon on many occasions, and is particularly interest-
ing on the present subject of compound frtictures. In these cases,
as is well known to practitioners, patients are often obliged to re-
main in their beds during many months, while disunited iicnes
and loose splinters cause inflammation and abscesses, which fur-
nish a discharge in such quantity as daily to inundate the ban-
dages and pillows.
The necessary changing and renewal of these has hitherto been
done at the expence of the surgeon's back, who in a stooping
painful posLure is obliged to support the heavy limb, often with the
additional weight of splints and bandages, (for he dares not trust
it in other hands,) while all the necessary apparatus is replacing.
This must be done by his direction; and often in a hurry to save
himself, as well as his patient, for his fatigue must necessarily in-
crease every instant, his hands must become unsteady, and the
fractured bones will consequently be often jarred and displaced,
which cannot fail of bringing on fresh pain and inflammation, and
retarding the cure. For fear of a repetition of all this trouble,
both patient and surgeon readily incline to put off" the evil day till
filth and putrid effluvia make it absolutely necessary to be re-
newed.
Whatever can tend to remedy or remove this great inconve-
nience, must, I presume, be esteemed a valuable acquisition by
all parlies concerned — surgeons, patients, and their attendants ;
and I have great pleasure in saying that this may be eflected by
the double bed. The bar which is added to it reaching from head
to foot at a proper height above the bed, and the ends of it turn-
ing down and being fixed in the two uprights which occasionally
raise the upper bed, will give a firm bearing, on which the limb
may at any time be suspended in a proper cradle or bandage,
while the nurses and attendants remove the dirty pillows, cleanse
the bed, and get every thing ready, while the surgeon is prepar-
AND DISLOCATIONS. 285
ing his apparatus, to replace it at his leisure, without hurrj, trou-
ble, or fatigue.
This, though a valuable, is but a secondary use of the bar; as it
was originally intended to raise the body of the patient, which
may be slung on it either by broad girths introduced under him;
or, if Ihat cannot be done, by the sheet on which he lies, the cor-
ners of it being tied over the bar. The u])rights then being dis-
engaged from their connexion with the upper bed, and the handle
being turned, the bar will be raised with the person attached to
it, and the upper bed will remain, on which may be put fresh
sheets, or what may be wanted: he will then be let down again,
and the sheet he has used may be drawn from under him; for it is
easy to draw or cut one away, though difficult to introduce a clean
one, while a person is lying in bed.
Many o her purposes may be served by this bar — for instance,
if there should be a wound or other complaint in the back, or
parts which could not be seen while the patient was lying down,
when he is by these means raised up, it may be examined, and
applications made to it, and other good effects may be produced by
the bar, which are noticed in the pamphlet. When the bar is not
wanted, it may be laid aside. E,
286 REMARKS ON FRACTURES
PLATE III.
In Plate III. is shown the bar, which has been described, raised up and
reaching from head to foot: it is fixed laterally in grooves made in the two
uprights which occasionally raise the upper bed, but in the present view they
sire unconnected with it, and merely act on the bar.
The dotted line marks how low the bar may be made to descend, in order
to receive any weight which may be attached to it, and which, with a steady
smooth movement, may be raised to any degree, from one inch to twenty, or
higher if required.
FLATJi 3
tofrontTaye 28f Vol.1.
\
AND DISLOCATIONS. 287
OF DISLOCATIONS IN GENERAL,
The principle inculcated so frequently in some of the foregoing
pages, concerning the extended or relaxed, that is, the resistant
or non-resistant state of the muscles, as depending on the posi-
tion of the limb, may be applied with equal truth and equal
advantage to dislocations, as to fractures. Neither of them can
indeed be rightly understood or judiciously treated without such
consideration. In both, a perfect knowledge of the disposition,
force, attachments, and uses of the muscles, at least those of the
limbs, are absolutely and indispensably necessary: and if the
young students would be careful in attending to the plain and obvi-
ous parts of anatomy; if they would with their own hands dissect
the muscles, tendons, blood-vessels and nerves; if they would
examine minutely the structure, dispositions, and connexions of
all the parts which form the various joints, with their ligaments,
and attend to the effects which the actions of the muscles and
tendons connected therewith must necessarily have on them, they
would have much more precise and adequate ideas of luxations,
than many of them have; they would have ideas of their own, not
taken upon trust from writers, who have for ages done little more
than copy each other; and they would act with much more satis-
faction to themselves.
By what our forefathers have said on the subject of luxations,
and by the descriptions and figures which they have left us of the
means they used, of what they called their organa and machine-
mata, it is plain that force was their object, and that whatever
purposes were aimed at or executed by these instruments or ma-
chines, were aimed at and executed principally by violence.
Many, or most of them indeed, are much more calculated to
pull a man's joints asunder, than to set them to rights. I will
not go so far as to say, that they are all equally bad or improper;
but I will venture to affirm, that hardly any of them are so con-
288 REMARKS ON FRACTURES
trived as to execute the purpose for which they should be used, in a
manner most agreeable, or most adapted to the nature or mecha-
nism of the parts on ivhich they are to operate, or to accomplish
such purpose in the most easy and most practicable manner; and
consequently, as 1 have already said, they act by force princi-
pally.
Nor is that all: some of them labour under another defect, and
that capable of producing great mischief; which is, that the force
or power of the instrument is not always determinable, as to
degree, by the operator, and consequently may do too little or too
much, according to different circumstances in the case, or more or
less caution or rashness in the surgeon.
I know very well that many of these are now laid aside, and
that some few have been so altered, as to become useful; but still
the same kind of principle, on which these inslruments were ori-
ginally founded and constructed, very generally prevails, and
violence is used, to the great fatigue, pain, and inconvenience of
the patient in many cases, in which dexterity, joined to a
knowledge of the parts, would execute the same purpose with
facility and ease.
In dislocations, as in fractures, our great attention ought to be
paid to the muscles belonging to the part affected. These are the
moving powers, and by these the joints, as well as other moveable
parts, are put into action: while the parts to be moved are in right
order and disposition, their actions will be regular and just, and
generally determinable by the will of the agent (at least in what
are called voluntary motions); but when the said parts are dis-
turbed from that order and disposition, the action or power of the
muscles does not therefore cease: far from it, they still continue
to exert themselves occasionally; but instead of producing regular
motions, at the will of the agent, they pull and distort the parts
they are attached to, and which by being displaced cannot perform
the functions for which they were designed.
From hence, and from hence principally, arise the trouble and
difficulty which attend the reduction of luxated joints. The mere
bones composing the articulations, or the mere connecting liga-
ments, would in general afford very little opposition; and the re-
placing the dislocation would require very little trouble or force,
AND DISLOCATIONS. 289
was it not for the resistance of the muscles and tendons attached
to and connected with them; for, by examining the fresh joints of
the human body, we shall find that they not only are all moved
by muscles and tendons, but also, that although what are called
the ligaments of the joints do really connect and hold them
togeiher, in such manner as could not well be executed without
them, yet, in many instances, they are, when stripped of all con-
nexion, so very weak and lax, and so dilatable and distractile, that
they do little more than connect the bones and retain the synovia;
and that the strength, as well as the motion of the joints, depends
in great measure on the muscles and tendons connected with and
passing over them; and this in those articulations which are de-
signed for the greatest quantity, as well as the celerity of motion.
Hence it must follow, that as the figure, mobility, action, and
strength of the principal joints, depend so much more on the mus-
cles and tendons in connexion with them, than on their mere liga-
ments; that the former are the parts which require our first and
greatest regard, these being the parts which will necessarily oppose
us in our attempts for reduction, and whose resistance must be
either eluded or overcome; terms of very different import, and
which every practitioner ought to be well apprised of.
From the same examination is to be obtained a kind and degree
of very useful information, which the skeleton cannot afford. I
mean an acquaintance with the ligaments themselves, both ex-
ternal and internal; the cartilages, both fixed and moveable; and
the parts furnishing what is called the synovia.
This, to those who are perfectly acquainted with the subjectj
may seem too obvious to have needed mention; but no one who
has not examined the joints can possibly have this kind of neces-
sary knowledge; and I am convinced that there are many practi-
tioners who have no idea of articulations, but what the assemblage
of dry bones has furnished them, and which must be very in-
adequate.
I have neither leisure nor inclination at present to enter into
this matter minutely, or indeed as it deserves; beside which, I
have, I fear, sufficiently exercised my reader's patience already iu
the foregoing sheets. I will therefore detain him no longer than
while I mention a few leading principles relative to luxations in
VOL. I. 0 0
290 REMARKS ON FRACTURES
general, drawn from ihe slruclure of the parts coriceracd, and
which cippear to me to be applicable, with very little if any varia-
tion, to every particular species.
1. Although a joint may have been luxated by means of con-
siderable violence, it does by no means follow, that the same de-
gree of violence is necessary for its reduction.
2. When a joint has been luxated, at least one of the bones of
which it is composed is detained in that its unnatural situation by
the action of some of the muscular parts in connexion with it;
which action, by the immobility of the joint, becomes, as it were,
tonic, and is not under the direction of the will of the patient.
3. That the mere bursal ligaments of some of the joints, endued
with great mobility, are weak, distractile, and constantly moisten-
ed; that for these reasons they are capable of suffering considera-
ble violence without being lacerated; but that they are also some-
times most certainly torn.
4. That, did the laceration of the said ligaments happen much
more frequently than I believe it does, yet it cannot be a matter
of very great consequence, as it neither totally prevents reduction,
when timely and properly attempted, nor a consequent cure.*^
5. That, supposing such accident to be frequent, yet as it is im-
possible to know, with any kind of certainty, whether it has hap-
pened or not, or in what part of the ligament, it cannot be ad-
* In the accident of a dislocated tibia, in consequence of a broken fibula,
the strong, inelastic, tendinous ligaments, which fasten the end of the former
bo7ie to the astragalus and os calcis, are frequently torn ; and as these by
proper care almost always do well, and recover all their strength, there is
the greatest reason to expect, that the more weak, distractile ones do the
same. The only mischief which seems most likely to follow from a lacerar
tion of the latter, is from an effusion of the synovia ; of which 1 think I have
(in a bad habii) seen an instance in the joint of the ancle. That the lacera-
tion of the bursal ligament of tlie shoulder cannot be a frequent or general
impediment to reduction, appears to me, from my never having, in more than
twenty years' care of an hvspital, met with a single instance of its imprac-
ticability, when attempted in time.
For it can hardly be supposed, that such kind of accident should never have
fallen to my lot, or to the people v/ho have acted under me.
But even if this could be supposed, I can also say, that I do not remember
impossibility of reduction to have happened to any of the other gentlemen of
the house, under the same clrcumslances.
AND DISLOCATIONS. 291
mitted as a rule for our conduct, nor ought such mere conjecture
to produce any deviation from what we ought to do, were there no
such supposition. Could we know with certainty when and where
this had happened, very useful information might indeed be drawn
from it.
6. That a!l the force used in reducin^j the luxited head of a
bone, be it more or less, be it by hands, towels, ligature.-, or ma-
chines, ought always to be applied to the other extremity of the
said bone, and as much as possible to that only.
Jn every joint capable of dislocation, the same circumstance
which renders it liable to be displaced, is also a very considerable
assistance in its reduction. I mean the dilatability or distraciile
power of the ligaments, their capacity of giving way when stretch-
ed or pulled at.
This is perhaps the strongest argument which can be produced,
why all the force made use of in reducing a dislocated joint should
be applied to that bone only, and not to the next. By the yielding
nature of the ligaraenis of the luxated joint, reduction is to be ac-
complished. The ligaments of the other articulation, which is
not luxated, are yielding also; and all the force which is applied
to the bone below or adjoining, must necessarily be lost in the
articulation which is not luxated, and can be of little or no service
in that which is.
Let this principle be applied to the dislocation of the joint of
the shoulder, and it will shew us why the ambi, in which the
whole arm is tied down, and subjected to the extending power of
the said instrument, is defective, and may be pernicious. Why
instruments built on the same general principle, but in which the
fore-arm is not fastened down, but left at liberty, and not subjected
to the ligature, execute their purpose with a great deal less force.
Whythe vulgar butfrequently very successful method of reducing this
joint, by placing the operator's heel in the axilla of the supine pa-
tient, sometimes fails, the surgeon not having proper assistance,
and contenting himself with pulling at the patient's wrist only. It
will also shew us, why, in the case of a luxated os femoris at the
joint of the hip, the strength of five or six people divided between
joint of ihe knee and that of the ancle, shall be insufficient; and
that of four, nav three of the same assistants, shall in the samjC
S92 REMARKS ON FRACTURES
case prove sufficient, by being all and properly applied to the
knee and femur only, as I have more than once seen.
Many other applications of this principle might be made, but
these are sufficient to those who understand the principle itself and
see its force.
7. That in the reduction of such joints, as are composed of a
round head, received into a socket, such as those of the shoulder
and hip, the whole body should be kept as steady as possible, for
the same reason as in the foregoing.
8. That in order to make use of an extending force with all pos-
sible advantage, and to excite thereby the least pain and inconve-
nience, it is necessary that all parts serving to the motion of the
dislocated joint, or in any degree connected with it, be put into
such a state as to give the smallest possible degree of resistance.
This I take to be the first and great principle by which a sur-
geon ought to regulate his conduct in reducing luxations. This will
show us why a knowledge of all the muscular and tendinous parts,
acting upon, or in connexion with the articulations, is absolutely
necessary for him who would do his business scientifically, with
satisfaction to himself or with ease to his patient. It will shew us,
that the mere position of the limb below the luxated joint, is what
must either relax or make tense the parts in connexion with that
joint, and consequently that posture is more than half of the busi-
ness. It will shew us, why sometimes the luxated os humeri slips
in, as it were, of its own accord, by merely changing the position
of the arm, when very violent attempts, previous to this, have
proved successless. It will shew us, why extending the arm in a
straight line horizontally, or so as to make a right angle with the
body, must, in some instances, render all moderate attempts fruit-
less. Why the method of attempting reduction by the heel in the
axilla is so often successful, notwithstanding two very considerable
disadvantages under which it labours; viz. part of the force being
lost in the elbow, and the tense state of one head of the biceps
cubiti. Why the tying down the fore-arm in the common anibi
is wrong for the same reasons. Why the fore-arm should at all
times, (let the method of reduction be what it may) be bent; viz.
because of the resistance of the long head of the biceps in an ex-
tended posture. Why, when the os humeri is luxat*"'' forward.
AND DISLOCATIONS. 293
or so that its head lies under the great pectoral muscle, the carry-
ing the extended arm backward, so as to put that muscle on the
stretch, renders the reduclion very difficult; and why, on the con-
trary, the bringing the arm forward, so as to relax the said muscle,
removes that difficulty, and renders reduction easy. Why the re-
duction of a luxated elbow should always be attempted by bond-
ing the said joint. Why, when the inner ancie is dislocated in
consequence of a fracture of the fibula, it is extremely difficult at
all times, and sometimes impracticable, either to reduce or to keep
reduced the said joint, while the leg is in an extended posture; and
why a bent posture of the leg enables us with ease to accomplish
both those ends. Why in the case of dislocation of the head of
the OS femoris, (be it in what manner it may,) a straight position
of the leg and thigh will always increase the difficulty of reduction;
and why that very distorted and bent position, in which the pa-
tient will always place it for his own ease, is and must be the
posture most favourable for reduction; because it is and must be that
posture in which the muscles, most likely to make opposition, are
most relaxed, and rendered least capable of resistances
9. That in the reduction of such joints as consist of a round
head moving in an acetabulum or socket, no attempt ought to be
made for replacing the said head, until it has by extension been
brought forth from the place where it is, and nearly to a level
with the said socket.
This will show us another fault in the common ambl, and why
that kind of ambl, which Mr. Freke called his commander, is a
much better instrument than any of them, or indeed than all; be-
cause it is a lever joined to an extensor; and that capable of being
used with the arm, in such position as to require the least exten-
g In the attempts for reduction of a luxated hip, there is one circumstance,
which, by being overlooked, or not attended to, has more than once rendered
every effort vain.
It is usual, and indeed necessary, to tie down and confine the patient on a
bed or table, in order to keep his body firm and steady: one part of the band-
age or strapping by which he is confined is fixed in the groin, and, passing
over his belly and under his buttock, is fastened above, or rather beyond, liis
head, to something immovable. If this bandage be placed (ste I have seen it)
in the groin on the side of the luxated bone, it will prove so far from being
assistant, that it will necessarily frustrate every attempt.
2.94 REMARKS ON FRACTURKS
sion, antl to admit the most; beside which it is graduated, and
therefore perfectly under the dominion of the operator.
It will show us, why the old method by the door or ladder
sometimes produced a fracture of the neck of the scapula, as I
have seen it do in our own time.
Why, if a sufficient degree of extension be not made, the towel
over the surgeon's shoulder, and under the patient's axilla, must
prove an impediment rather than an assistance, by thrusting the
head of the humerus under the neck of the scapula, instead of di-
recting it into its socket.
Why the bar or rolling-pin under the axilla produce the same
effect.
Why the common method of bending the arm (that is, the os
humeri) downward, before sufficient extension has been made,
prevents the very thing aimed at; by pushing the head of the bone
under the scapula, which the continuation of the extension for a
few seconds only would have carried into its proper place.
I know it is said, that mere extension only draws the head of
the bone out from the axilla, in which it was lodged, but does not
replace it in the acetabulum scapulae. To which I uill venture
to answer, that when the head of the os humeri is drawn forth
from the axilla, and brought to a level with the cup of the scapu-
la, it must be a very great and very unnecessary addition of extend-
ing force, that will or can keep it from going into it. All that the
surgeon has to do is to bring it to such level: the muscles attached
to the bone will do the rest for him, and that whether he will or
not.
Indeed, if all the rational means and methods for reducing a
luxated shoulder be examined, they will be found to ac! upon this
principle, however differently ibis matter may appear to those
who have not attended to it. Even the common am!>i succeeds
by means of the extension, which the carrying ihe arm down with
it produces, and not by its lever. That part of the instrument, so
far from helping, is often a considerable hinderance, and even
sometimes frnstrates the operator's intention, by pushing the head
of the bone ai^ainstthe scapula, before it is sufficiently drawn out
from the axilla.
If it was necessary to add any thing in support of this doctrine.
AND DISLOGATIONS. 295
1 should say, that the supposition of laceration of the bursal liga-
ment being a circumstance frequently attending this luxaiion, and
proving an impediment to reduction, is a strong inducement to us
to be always attentive to the making such extension, it being
much more likely that the head of the bone should return back
by the same rent in the ligament, when such ligament is mode-
rately stretched out, than when it may be supposed to lie
ivrinkled or in folds.
10. The last principle which I shall take the liberty to men-
lion, and which I would inculcate very seriously, is, that what-
ever kind or degree of force may be found necessary for the re-
duction of a luxated joint, that such force be employed gradually,
that the less degree be always first tried; and that it be in-
creased gradatim.
Whoever reflects on what is intended by extension, what the
parts are which resist, and how that resistance may be best over-
come, will want little argument to induce him to accede to this
principle; the advantages deducible from attending to it, and the
disadvantages ivhich may and do follow the neglect of it, are so
obvious.
They who have not made the experiment will not believe to
how great a degree a gradually increased extension may be car-
ried without any injury to the parts extended; whereas great force,
exerted hastily, is productive of very terrible, and very lasting
mischief.
I know that the vis percussionis, as it is called, has been re-
commended as having been successful in some difficult luxations;
but I have seen such bad consequences from it, that I cannot help
bearing my testimony against it. The extensile and distractile
quality of the membranes, muscles, and ligaments, enables them
to bear the application of very great force to them, without hurt,
if such force be applied gradually, and proper time be allowed
for the parts to give way in; but great force, suddenly applied, is
capable of producing the most mischievous consequences; and
that in many other parts of surgery, beside what relates to luxa-
tions.^
^ I sliall take the liberty to remark here, that in obstinate and difficult dis-
locations, the least painful aad most effectual method of reducing them ap-
296 REMARKS ON FRACTURES, &C.
pears to me to he by means of a pulley, by which the extension may be
madi in any direction ; and the force may be applied with precision, as gra-
4^ually and to as great a degree as may be thought necessary, by the assist-
ance of one person only, which is infinitely preferable to a number of people
pulling in diOerent directions. Even in an hospital, where there are a sufficient
number who al! know what they are about, and what end is to be answered,
many hands must pull irregularly, as they draw from different points; and
this inconvenience must be much greater in private practice, where the as-
sistants are ignorant and awkward. The patient may also be kept more
firm and steady, by means of a broad leathern belt, lined with soft flannel,
which surrounds tiie tiiorax, and is fixed to a post or some immovaole body,
than by any number of assistants, making a counter extension. This plan, 1 am
convinced, is preferable to the ambi, or any means 1 have ever seen em])loyed
in obstinate cases of dislocated humeri, and may be applied very advanta-
geously to luxations of the os femoris. By the methods commonly in use,
the limbs are often so bruised and excoriated, that, if the reduction be not
effected by the first, a considerable tinne is lost before the inflammation can
be sufficiently dissipatf d to permit another attempt. The thick buff leather
T/hich guards the skin from the pressure of the chord of the pulley, pre-
vents such disagreeable consequences from taking place. E.
TREATISE
RUPTURES.
XOh. I. ? p
PREFACE,
The disease which makes the subject of the following tract, is
one in which mankind are, on many accounts, much interested.
No age, sex, rank, or condition of life, is exempt from it; the rich,
the poor, the lazy, and the laborious, are equally liable to it; it
produces certain inconvenience to all who are afflicted by it; it
sometimes puts the life of the patient in such hazard, as to require
one of the most delicate operations in surgery; and it has in all
times, from the most ancient down to the present, rendered those
who labour under it subject to the most iniquitous frauds and im-
positions.
The generality of mankind look upon a rupture as an imper-
fection in their form, as a disease which impairs their strength,
and lessens their generative faculty: which apprehensions, though
absolutely groundless, are so firmly rooted in the majority of those
who are afflicted with the disorder, as to make them not a little
miserable. They who lie in wait to avail themselves of the weak-
nesses of the infirm and fearful, are well acquainted with these
fears, and very lucrative use do they make of them. They well
know, that the man who regards his disorder as an imper-
fection in his form, or as a cause of any debility, more particularly
a venereal one, will be very unwilling to have it known, and as
glad to get rid of it, at any expense or trouble: by this means these
impostors are furnished with opportunities of subjecting the igno-
rant and credulous to tedious confinements, painful applications,
300 PREFACE.
and even hazardous operations; and of defrauding the timorous
and bashful of large sums of money, for imaginary diseases, and
pretended cures.
Complaints of this sort, coming from the profession, are gener-
ally ill received; and, being set to the account of prejudice, inte-
rest, and craft, are very little regarded; but in this mankind do us
great injustice. A rupture is a disease, which, if judiciously and
honestly treated from the first, can never be productive of much
profit 10 a surgeon; it requires very little attendance, and neither
external application nor internal medicine. Though the reduction
of the gut, and the application of a proper bandage, are necessary,
yet ihis is in general so soon and so easily accomplished, that it
must be obvious that no great emolument can from thence be
derived; and therefore, if the profession may be allowed to be
impartial in any thing which relates to themselves, I think they
may in this, from which they never can reap considerable profit,
unless the disease has been greatly neglected, or ill-treated. It
is from fraud and delusion principally that such advantage can be
derived; it is from the patient's ignorance of the true nature of
bis disorder, and from bold and lying promises m.ade of a perfect
cure.
It is far from my intention to defend the body of surgeons from
any accusation which may justly be brought against them; but
as the reason given by most of the patrons of quackery for their
supporting it, is, that the medical world, through mere obstinacy,
never depart from the customs of their ancestors, nor attempt any
thing niew, though mankind might be much benefitted by such in-
ventions; and as I think that such imputation cannot with any
colour of justice be made against us, I would beg leave to be in-
dulged a few words on this subject.
That the merit of many of the old practitioners was great; that
they left behind them many proofs both of their sagacity and their
PREFACE. 801
dexterity; that we have received large information from their
writings; and that, cceteris paribus^ he who is best acquainted with
them will be the best surgeon, is well known to every one who
is at all conversant with them, and can be denied only by those
who are not. But, on the other hand, it must also be allowed,
that both their theory and their practice laboured under great
disadvantages, which rendered their judgment of many diseases
erroneous, and their treatment of them irrational and unsuccessful.
The very imperfect state of their anatomy was one great source
of error; which kind of knowledge has been so cultivated in our
times as to convert ignorance into a vice, and to render those
who are deficient in it perfectly inexcusable.
As this is the only true and solid basis from which all chirur-
gical knowledge must for ever spring, so it has of late years been
productive of many real and great improvements in the art.
The ancient surgery was coarse, and loaded with a farrago of
external applications, some of which were horridly, and yet un-
necessarily painful, and others altogether useless; whilst the ope-
rative part of the art was encumbered with a multitude of awk-
ward unmanageable instruments, and pieces of machinery.
The practitioners of the present time have brought the practice
into a much narrower compass, have rendered it less painful and
more intelligible; they have reduced the number of instruments,
and by the extreme simplicity of those which they now use, they
have considerably assisted (he dexterity of an operator, and
shortened the time of an operation; they have almost thrown
aside the burning cautery, and are much more sparing in the use
of caustic applications than their predecessors used to be; they
now accomplish many cures by mild and gentle means, which
formerly were thought not obtainable but by much severity; to
say nothing of the indelible marks which such practice left be-
hind it. The havoc formerly made both of limbs and lives, by
302 PREFACE.
the use of long forceps in gun-shot wounds; the explosion of the
long-prevaiiing notion that such wound were poisonous; the easy
superficial meuiod in which they are now in general treated, and
the opportunities which such treatment gives for nature to exert
those powers with which the Ahuighiy Author has furnished "her,
do credit to the modern practitioners; the double incision in am-
putations; the present method of removing cancerous breasts, and
encysted tumours; the lateral operation for the stone in the blad-
der; the use of the cutting gorget; amputation in the joint of the
shoulder; the present method of letting out all the water at once
from an ascites; the impro\emenis in the treatment of the fistula
lachrjmalis; the cure of the vari and valgi, with many othere
which might be named; in short, the superior neatness, ease, and
expedition of the present surgery, when compared to the ancient,
are certain and undoubied improvements made by the modern
practitioners, and such as mankind are much benefitted by, as
their pains are thereby lessened, the elegance of their figure pre-
served, and the time of their confinement shortened; ail which
will, I presume, be allowed to be advantages, while human na-
ture shall remain sensible of pain, while scars shall be thought
deformities, or confinement be deemed irksome.
Nor is our conduct, with regard to the particular disease which
makes the subject of the following tract, in the least degree blame-
able; so far from it, that the treatment which we meet with some-
times is most singularly unjust, we being often severely censured
for that from which we ought to derive praise: so little do we de-
serve the reflection cast upon us, of being content with what our
fathers taught us, and neither improving the art ourselves, nor
encouraging those who do: that, on the contrary, much pains have
been taken to improve this particular part of surgery, and the pub-
lic ought to thank us for not persevering in the use of the old,
tedious, painful, and hazardous processes, after we found them
to be in general ineffectual.
]fEEPAC£. 303
But though I would at all times vindicate the profession from
€very unjust attack. I would by no means be supposed to think
that there is not large room left for the industry bo(h of us and
our successors; some of the operative parts of the art are still ca-
pable of improvement, and the treatment of some diseases might
certainly be altered for the better.
Whether our future labours shall be crowned with success or
not, sfill I think it will appear to every one at all versed in the
history of surgery, that the practitioners of the present time are
so far from deserving the character which they who know nothing
of the art have given of them, that they really deserve a very con-
trary one; since instead of obstinately adhering to the practice of
their ancestors, they have differed from it in many instances,
where they found they could do it with safety, and to the advan-
tage of mankind; and have endeavoured to advance the utility of
their profession, by the only means whereby it is capable of being
improved, viz. by a sedulous application to anatomy, by the fre-
quent examinations of dead morbid bodies, and by making such
experiments on the living, as they had just reason to think would
prove beneficial; candidly acknowledging at the same time, where
they have found their art insufficient, and not persisting in tor-
menting their fellow-creatures merely for gain.
In the following treatise I have endeavoured to express myself
in as plain,' explicit, and intelligible a manner as f am able, and
the subject will admit; being desirous as much as I can to inform
mankind of the true nature of the disease, of the danger they in-
cur, and the frauds they are liable to, from the ignorance of one
set of quacks, and the worse qualities of another: to show what
the art of surgery in judicious hands is capable of doing, and how
essentially the conduct of an impostor differs from that of an honest
-man, who will never be ashamed of confessing that he ran not de
what is not in his power.
304 PREFACE.
In the first edition of this book were many faults; some of
the press, some of the author: in this some pains have been
taken to lessen both. Of typographical errors very few, if any,
will, I hope, be found; and wherever it has appeared to me that
the matter of the treatise was obscure, erroneous, or deficient, I
have altered, corrected, and added to it.
I am still far from thinking that it is perfect or faultless; but on
the other hand, I am not conscious of having advanced any thing
in it which is not strictly true, and agreeable to the most success-
ful practice. Improvement of the art of surgery, and the relief
of mankind, are my two principal objects; and if what I have
now, or at any other time written, shall be found to have con-
tributed toward accomplishing either of those ends, I hope the
reader will excuse all those lesser faults,
qiias au' i:. curia fudit,
Aut humana parum cavil natura.
A TREATISE, &c.
SECT. I.
Bf the term ruphure, descent, or hernia, is in general meant
a swelling produced by the falling down or protrusion of some
part or parts, which ought naturally to be contained within the
cavity of the belly.
The places in which these swellings make their appearance, in
order to form what is called a rupture, are the groin, the navel,
the labia pudendi, the upper and fore part of the thigh, and every
point of the anterior part of the abdomen.
The parts, which, bj being thrust forth from the cavity in which
they ought naturally to remain, form these tumors, are a portion of
the omentum, a part of the intestinal canal, and sometimes* (though
very rarely) the stomach.
From these two circumstances, of situation and contents, are
iJerived all the ditferent appellations by which herniae are dis-
tinguished: for example, they are called inguinal, scrotal, ferno-
'-al, umbilical, and ventral, as they happen to make their appear-
ance in the groin, scrotum, thigh, navel, or belly. If a portion
of intestine only forms it, it is called enterocele, hernia intestinalis^
or gut-rupture; if a pi«ce of omentum only, epiphcele, hernia omen-
talis, or caai-rupture; and if both intestine and omentum conlri-
» The liver, spleen, uterus, bladder, 8;c. have at different times been found
in different hernice. but these are so rare as not to oome Vv?ithin a g^eneral
description.
VOL. T. Q q
306 A TREATISE ON RUPTURES,
bute mutually to the formation of the tumor, it is called enieroepi'
plocele^ or compound rupture.
If the piece of gut or caul descends no lower than the groin, it
is said to be incomplete, and is called bubonocele; if the scrotum
be occupied by either of them, the rupture is said to be complete,
and bears the name of oscheocele: the latter used by our fore-
fathers to be attributed to laceration of the peritoneum, the former
to its dilatation merely.
The opinion, that the scrotal hernia is occasioned by a forcible
division, or breach made in the peritoneum, has always been, and
still is, with the unknowing, a very prevailing one, though with-
out any foundation in truth; both the scrotal and femoral pass out
from the abdomen by openings which are natural to every human
body; as well those who have not ruptures,- as those who have.
The former, that is the scrotal, descend by means of an aperture
in the tendon of the external oblique muscle, near the groin; de-
signed for the passage of the spermatic vessels in men, and the
ligamenta uteri in women; and the latter, under the hollow made
by Poupart's, or Fallopius's ligament, at the upper part of the
thigh, along with the great crural vein and artery.
The pair of muscles called obliqui externi ascendentes, cover all
that part of the belly which is without bone, and the lower and
anterior parts of the thorax. They are fleshy on the sides, and
tendinous in the middle and lower part ; they spring from the
seventh and eighth ribs, and from all below them, by fleshy portions
which indigiiate with corresponding parts of two other muscles,
called the serratus major anticus, and the latissimus dorsi, and
becoming tendinous, are inserted into what is called the linea
alba, the spine of the os olium, and into the os pubis.
At the lower part of the belly, on each side, a little above the
last mentioned bone, the fibres of the tejidon of this muscle
separate from each other, and form thereby two apertures, through
which pass (he spermatic vessels in men, and the ligamenta uteri
in women. These openings are of an oval figure, and have an
fblique direction from above downward: the upper part of them
A TREATISE ON RUPTURES. 307
is rather wider than the lower, and they are of larger size in men
than in women.'*
The tendinous fibres of this muscle, as they proceed from its
fleshy part obliquely downward, have several small apertures for
the passage of vessels and nerves; and at their insertion into the
OS pubis, they cross one another, and are as it were interwoven, by
which means their insertion is strengthened, and their attachment
made firmer.
What is called by the particular name of Poupart's ligament is
really nothing more than the lower border of this tendon, stretch-
ed from the fore part of the os ilium, or haunch bone, to the
OS pubis, and turned or folded inward at its interior edge.
The other muscles of the belly are the obliquus internus, the
transversalis, the rectus, and the pyramidalis, none of which have
any concern with our present subject. The spermatic chord does
indeed pass under the lower edge or border of the two first of
these, but at such a distance, and in such manner, that no action
©f these muscles can any way affect, or ever make any stricture
either on it, or on a hernia accompanying it; they have no per-
forations, or apertures, though so many writers of credit (even
late ones) have both described and delineated them,*^ consequently
*> A detachment of fibres from the fascia lata of the thigh is generally
united with the tendon composing the aperture in tiie obliquus externus,
which mixture or connexion of fibres will in some measure account for the
pain which they who labour under strangulated ruptures feel upon standing
upright, and the relief which bending the tiiigli upward toward the belly
always gives them.
•= However incredible and strange it may seem, yet I am convinced, that
operations have been performed by the information obtained from books only,
witliout any previous anatomical knowledge, any practice on dead bodies,
and barely any, if any, opportunities of seeing such operations performed by
o^Iiers on the living : how grossly must such an operator be deceived by the
account of the rings, as they are usually, though absurdly called, of the abdo-
minal muscles: after he has divided the first, or that of the external oblique,
he will expect to find a second in the internal, and a third in the transversalis,
and will never suppose that he is got into the cavity of the belly, till he has
divided all the three: it is therefore of the utmost consequence that this
matter be set right, and that, notwithstanding what has been said on this
subject by writers of great eminence, every surgeon be informed that the
external oblique muscle is the only one which hfis any opening in it; that the
308 A TREATISE ON RUPTURES.
they can have no share in the embarrassment of the parts con-
tained in a hernial sac, nor require any division in that operation,
which becomes sometimes necessary towards setting them free:
which is a fact of no small consequence to an operator.
The inside of these muscles, and indeed the whole cavity of
the belly, is lined with a smooth, firm, but easily dilatable mem-
brane, called (he peritoneum, a minute account of which would
lead me beside my present purpose, and therefore I shall only
observe, that it lines the whole abdomen, and gives an external
coat to every viscus contained in it.
Behind the peritoneum lies a loose, cellular membrane, by
some called its appendix, which is ibund in different quantity in
different places. In some the cells are empty, and are immedi-
ately visible upon being blown into; in other parts it is plentifully
stocked with fat, and, though somewhat varied in its appearance
in different places, is found in most parts of the body.
This cellular me.mbrane, void of fat, surrounding the sperma-
tic vessels, as they pass forth from the cavity of the abdomen into
the groin, is called, the tunica vaginalis of the chord, or tunica
communis vasorum spermaticorum; which chord, thus enveloped,
passing under the inferior edge or border of the transversalis, and
internal oblique muscles, and through the perforations or natural
apertures of the external oblique, descends through the groin to
the testicle, in such manner, that the spermatic vessels in their
passage from the cavity are really and truly behind the perito-
heum.
The tunica vaginalis testis is a membrane perfectly distinct
from this, forming a particular cavity, which includes the glan-
dular substance of the testicle, and has nothing to do with a com-
mon rupture. In every foetus, until, or very near until the time
of birth, there is an open and free communication between the
cavity of this last tunic, and that of the belly, for the passage of
the testicle from the abdomen into the scrotum: soon after birth
description given by Mr. Clieselden of these muscles, in the last edition of
his anatomy, is erroneous; and all descriptions and all delineations (some of
which are to be found even in later writers) of more openings than that
sinqle oiie on each side, are not representations of nature, but are the images
of a luxuriant fancy, and have no foundation in truth.
A TREATISE ON RUPTURES. 309
this passage closes and becomes impervious; nor is there ever
after the time of such closing, any communication between the
cavity of the belly, and that of the tunica vaginalis testis. But
though the passage remains in general for ever shut, yet the
place where its orifice, or mouth, was, may always be known by
a kind of cicatricula, much like to what appears within the abdo-
men, opposite to the navel, or place where the umbilical vessels
of the foetus passed to and from the placenta; at the place of
which cicatricula, the peritoneum is generally weaker than else-
where. Now, if it be remembered, that this weak part is neces-
sarily opposite to the natural opening in the tendon of the external
oblique muscle; that neither the internal oblique muscle, nor the
transversalis, comes low enough to make any resistance to what-
ever shall press against this part; and that the acknowledged use
of the muscles of the abdomen is by pressing on all its contained
viscera to assist digestion, the expulsion of the faeces, urine, and
fcetus; (and that in many natural actions, such as sneezing and
coughing, &c. and in all great exertions of strength and force, our
erect posture must necessarily occasion a pressure to be made
against the lower part of the inside of the belly, by some of its
contents;) a very probable and satisfactory account of the origin
of the common inguinal and scrotal hernia may be collected.
In young children, this descent or protrusion happens most fre-
quently when the child strains in crying, or in expelling its fsces;
as soon as the effort ceases, and the child is quiet, the part gene-
rally returns up again, and the swelling disappears. The nurses
call it wind, and it is at first most frequently neglected, as the
child is not apparently injured by it, and hw people are suffi-
ciently aware of its possible consequences.
Not that the disease is by any means confined to children-
adults frequently are attacked by it, either by falls, strains, great ex-
ertions of strength, difficulty of expelling hard fseces, or a general
laxi y of frame.
Whether the rupture be inguinal, scrotal, or femoral, and whe-
ther it consists of intestine, or omentum, or both, the protruded
part must c rry before it a part of the membrane which lines all
the internal surfa.e of the abdominal muscles, or rai her the whole
cavity of the abdomen, and is called peritoneum. This portion of
310 A TREATISE ON RUPTURES.
the peritoneum, including the piece of gut or caul, is known by
the name of the hernial sac, and is larger, or smaller, according to
the quantity of intestine, or omentum, contained in it: it is at first
small and thin, and in ruptures which are not of the congenial
kind, seldom comes lower than the groin'" at first, but by repeated
descents it extends itself lower and lower, till it gets quite into
the scrotum, and still as it is extended in length, it becomes
thickf.T and firmer in texture, till in old age, or old ruptures, it is
found of very considerable thickness.
As all parts of the peritoneum are of a very extensible, di-
latable nature, and as the hernial sac has this property in common
with many o'dier parts of the body, of thickening as it extends, it
does in some cases stretch to a very considerable size, and con-
tain such a quaniity of intestine and omentum as is almost incre-
dible. This circumstance of its becoming thicker as it is more
extended, is perhaps the reason why some people, and among
them the late Mr. Cheselden, have been of opinion that the sac
of a hernia was not an elongation of the peritoneum, but pro-
duced like that of an aneurism, and some other tumors, by mere
pressure of the common cellular membrane; an opinion, which is
maniteslly and demonstrably erroneous.
Whether the hernial sac in its infant state, while it is very thin,
and may possibly have contracted no adhesion to the cellular
membrane composing the tunica communis of the spermatic ves-
sels, does ever return back into the belly again, I will take upon
me to determine absolutely; but am much inclined to think it
does not, as well from the facility with which the gut or caul
most commonly descends after they have been down a few times,
as from a fulness which is always to be perceived in the sperma-
tic process of such people as have ever been ruptured. Some few
of these I have had opportunities of opening after death, and have
always found the sac, either in the groin or scrotum, (plainly a
continuation of ihe peritoneum,) remaining firmly attached to, and
"^ 1 will not say positively that all those ruptures which appear in the scro-
tum of very young children are congenial, (that is, have the tunica vaginalis
testis for their hernial sac,) but all those which I have had an oi)portunity of
examining have proved so ; and I believe it would be no erro'teous criterion,
whereby to distinguish the common ruptiu*e from the congenial, in infants.
A TREATISE ON RUPTURES. 311
connected with, the tunica communis: nor did I ever see, either
in the dead or the living, any reason or authority for the supposi-
tion, that it is capable of returning back into the abdomen after
it has been fairly pushed out through the aperture in the tendon. «
I intentionally avoid saying any thing about the old doctrine of
the difference between dilatation and laceration of the peritoneum,
it being now generally known and acknowledged, that to what-
ever size the hernial sac may be extended, and however large its
contents may be, it is merely dilated, and hardly ever burst or
broken: the particular kind of case, which a few years ago gave
rise to a sort of renewal of the old doctrine of ruptures by the la-
ceration of the hernial sac, viz. that kind of hernia in which the
gut and testicle are found in the same bag, and in immediate con>-
tact with each other, being now sufficiently known and explained.
See Sec. X. of this Tract,
The signs, or marks, of a common inguinal or scrotal rupture,
are in general a swelling in the upper pan of the scrotum, or in
the groin, beginning at the opening in the abdominal muscles
where the spermatic vessels pass down from the belly; which tu-
mor has a different appearance, and different feel, according to
the nature of its contents, and to the state and quantity of them.
If a portion of intestine forms it, and that portion be small, the
tumor is small in proportion; but though small, yet if the gut be
distended with wind, inflamed, or have any degree of stricture
made on it, it w^ill be tense, resist the impression of the finger,
« This is a circumstance of some impovtance in the general treatment of
ruptures. Upon it depends the truth or falsehood of the late doctrine of the
possibility of returning the intestine included in the hernial sac, and con,
fined by such a stricture of the sac itself, as may prove fatal after the gut is
fairly got into the abdomen again. A case, of which more than one instance
has been given to us, but in which I am much inclined to believe that some
mistake has been made, and which I also think may be accounted for in an-
other and more satisfactory manner. Upon this also depends the practicability
or impracticability of returning a strangulated piece of gut back into the beliy,
after having divided the stricture made by the tendon, without opening the
liernial sac, and consequently the propriety or impropriety of making sncli
attempt. All endeavours to do what is impracticable, being, in cases of im-
portance, much worse than doing nothing.
31^ A TREATISE ON RUPTURES.
and give pain upon being handled. On the contrary, if there be
no stricture made by the tendon, and the intestine suiftrs no de-
gree of infldmmation, let the prolapsed piece be of what length it
may, and the tumor of whatever size, yet the tension will be little,
and no pain will attend the handling it: upon the patient's cough-
ing, it will feel as if it was blown into, and in general it will be
found very easily returnable. If the hernia be of the omental
kind, the tumor has a more flabby and a more unequal feel: it is
in general perfectly indolent, is more compressible, gives the
scrotum a more oblong and less round figure, than it bears in an
intestinal hernia; and if the quantity be large, and the patient
adult, it is in some measure distinguishable by its greater
weight.
If it consists of both intestine and omentum, the characteristic
marks will be less clear than in either of the simple cases, but
yet will to any body who is accustomed to these diseases be suffi-
ciently so, to enable them to distinguish it from any other com-
plaint.
The only diseases with which a true hernia can be confounded,
are the venereal bubo^ the hydrocele, and that defiuxion on the tes-
ticle, called hernia humoralis; from each of which it is certainly
very distinguishable.
The circumscribed incompressible hardness, the situation of
the tumor, and its being free from all connexion with the sper-
matic process, will sufficiently point out the firsts at least while it
is in a recent state; and when it is in any degree suppurated, he
must have a very small share of the tactus eruditus, who cannot
feel the difference between matter, and either a piece of intestine
or omentum.
The perfect equality of the whole tumor, the freedom and small-
ness of the spermatic process above it, the power of feeling the
spermatic vessels, and the vas deferens in that process, its being
void of pain upon being handled, the fluctuation of the watef, the
gradual formaLion of the swelling, its having begun below and
proceeded upwards, its not being affected by any posture or ac- .
tion of the patient, nor increased by his coughing or sneezings
together with the absolute impossibility of feeling the testicle at
A TREATISE ON RUPTURES. SIB
the bottom of the scrotum/ will always, to any intelligent person,
prove the disease to be a hydrocele of the tunica vaginnlis testis.
And in the hernia humoralis, the pain in the testicle, iis enlarge-
ment, the hardened slate of the epiiUdinsis, and (he exemption of
the spermatic chord from all unnatural fuhiess, are such marks as
cannot easily be mistaken: not to mention the generally preceding
gonorrhea. But if any doubt still remains of the true nature of
the disease, the progress of it from above downward, its different
state and size in different postures, particularly lying and stand-
ing, together with its descent and ascent, will, if duly attended to,
put it out of all doubt, that the tumor is a true hernia.
If an attempt be made for the reduction of the rupture, and it
consisted of a piece of intestine, it generally slips up all at once.
In its return it makes a kind of guggling noise; and when it is np,
the scrotum and process will be found free from any preternatural
fulness. If a portion of omentum formed it, it retires more gra-
dually, without any of the noise of the former, and requires to be
followed by the finger to the last. If both gut and caul contri-
buted to the formation of it, the gut generally goes up first, and
leaves a flabby irregular kind of body behind it, which still pos-
sesses the process or scrotum, according as the disease was bu-
bonocele, or oscheocele, and requiring still farther compression,
at last ascends.
The intestine said to be most frequently found in a scrotal her^
nia, is the ileum, though it is also allowed that the caecum and
part of the colon have been met with.
This is one of the many maxims which writer receives from
writer, and inattentive readers all believe.
f By this remark it may possibly be thought that I mean to say, that the
testicle is alwajs to be felt at the bottom of the scrotum in a true hernia;
which in general is true, but not without some exceptions. In recent rup-
tures, of the common kind, whether of the gut or caul, while the hernial
sac is tliiii, has not been long or very much distended, and the scrotum still
preserves a regularity of figure, the testicle may almost always be easily felt
at the inferior and posterior part of the tumor: but in old ruptures, which
have been long down, in wliich the quantity of contents is large, the sac con-
siderably thickened, and the scrotum of an irregular figure, it often happens
that the testicle is not to be felt, neither is it in general easily felt in a con-
genial heniia, for very obvious reasons.
VOL. I. R r
314 A TREATISE ON RUPTURES.
That a portion of the ileum does often descend in a hernial sac
is beyond all doubt; but that the descent, or more proper y pro-
perly protrusion, of a part of the caecum and colon is rare, is not
true, for it happens very frequently. Perhaps it would not bear
to be established as a general rule; but from what has ftdlen
within my observation, in frequently performing the operation for
a strangulated rupture, it has appeared to me, that the greater
number of those in whom it has become necessary, (all attempts
to reduce the parts by hand having proved fruitless,) have con-
sisted of the caecum with its appendicula, and a portion of the co-
lon. Nor will the size, disposition, and irregular figure of this
part of the intestinal canal, appear upon due consideration a very
improbable cause of the difficulty or impossibility of reduction by
the hand only.
I have already mentioned the principal circumstances by which
hernias are distinguishable from other diseases. But it is also
to be observed, that the same kind of rupture in different people,
and under different circumstances, wears a very various face; the
age and constitution of the subject, the date of the disease, its be-
ing free or not free from stricture or inflammation, the symptoms
"which attend it, and the probability or improbability of its being
returnable, necessarily producing much variety: the degree of
hazard attending this complaint will be also more or less as it
shall happen to be circumstanced.
If the subject be an infant, the case is not often attended with
much difficulty or hazard; the softness and ductility of their fibres
generally rendering the reduction easy as well as the descent;
and though from neglect or inattention it may fall down again,
yet it is as easily replaced, and seldom produces any mischief: I
say seldom, because I have seen an infant, one yeor old, die of a
strangulated hernia, which had not been down two days, with all
the symptoms of mortified intestines.
If the patient be adult, and in the vigour of life, the conse-
quences of neglect, or of maltreatment, are more to be feared than
at any other time, for reasons too obvious to need relating. The
great and principal mischief to be apprehended in an intestinal
hernia, is an inflammation of the gut, and an obstruction to the
passage of the aliment, and faeces through it; which inflammation
A TREATISE ON RUPTURES. 315
and obstruction are generally produced by a stricture made on the
intestine, by the borders of the aperture in the tendon of the abdo-
minal muscle, through which the hernia and its sac pass. Now
it must be obvious, that the greater the natural strength of the sub-
ject is in general, and the more liable to inflammation, the greater
probability there must be of stricture, and the more mischief likely
to ensue from it. In very old people, the symptoms do not usually
make such rapid progress, both on account of the laxity of their
frame, and their more languid circulation; and also that their
ruptures are most frequently of ancient date, and the passage con-
siderably dilated: but then, on the other hand, it should also be
remembered ihat they are by no means exempt from inflammatory
symptoms; and that if such should come on, the infirmity of old
age is no favourable circumstance in the treatment which may
become necessary.
If the disease be recent, and the patient young, immediate
reduction, and constant care to prevent its pushing out again, are
the only means whereby it is possible to obtain a perfect cure.
If the disease be of long standing, has been neglected, or suf-
fered to be frequently down, and has given little or no trouble, the
aperture in the abdominal muscle, and the neck of the hernial sac,
may both be presumed to be large; which circumstances in gene-
ral render immediate reduction less necessary and less difficult,
and also frustrate all rational expectation of a perfect cure. . On
the contrary, if the rupture be recent, or though old has generally
been kept up, its immediate reduction is more absolutely neces-
sary, as the risk of sU'icture is greater from the supposed smallness
of the aperture, and narrowness of the neck of the sac. If the
rupture be very large and ancient, the patient far advanced in
life, the intestine not bound by any degree of stricture, but does
its office in the scrotum regularly, and no other inconvenience be
found to attend it, but what proceeds from its weight, it will in
general be better not to attempt reduction, as it will in these cir-
cumstances most probably prove fruitless, and the handling of the
parts in the attempt may so bruise and injure them as to do mis-
chief: but this must be understood to be spoken, of those only in
which there is not the smallest degree of stricture, nor any symp-
31& A TREATISE ON RUPTURES.
torn of the obstruction in the intestine; such circumstances making
reduction necessary at all times, and in every ( ase.
With regard to the contents of a hernia, if it be a portion of
omentum only, nd has been gradually formexl, it seldom occasions
any bad symptoms, though its weight will sometimes render it
very troublesome. But if it be produced suddenly by effort or
violence, that is, if a considerable piece of the caul by accident
slip down at once, it will sometimes prove painful, and cause very
disagreeable complaints; the connexion between the omentum,
stom xh, duodenum, &c. being such as to render the sudden
dL-sccBi of a large piece of the first sometimes productive of nausea,
vomiting, colic, and ail the disagreeable symptoms arising from
the derangement of these viscera. When the piece of caul is
engaged in such a degree of stricture as to prevent the circulation
of blood through it, it will sometimes, by becoming gangrenous, be
the occasion of very bad symptoms, and even of death, as I have
more than once seen: and thus, as a mere oraeniai hernia, it may
sometimes be subject to great hazard. But even though it should
never be liable to the just mentioned evil, that is, though the por-
tion of the caul should remain uninjured in the scrotum, yet it
renders the patient constantly liable to hazard from another quar-
ter: it makes it every moment possible for a piece of intestine to
slip into the same sac, and thereby add to the case all the trouble
and all the danger arising from an intestinal rupture. It is by no
means an uncommon thing for a piece of gut to be added to a
rupture, which had for many years been merely omental, and for
that piece to be strangulated, and require immediate help.
An old omental hernia is often rendered not reducible, more by
an alteration made in the state of the prolapsed piece of caul, than
by its quantity. It is very common for that part of the omentum
which passes through the neck of the sac to be compressed into a
hard, smooth body, and lose all appearance of caul, while what is
below in the scrotum is loose and expanded, and enjoys its natural
texture. In this case reduction is often impossible, from the mere
figure of the part; and I have so often seen this, both in the living
and the dead, that I am satisfied, that for one omental rupture
rendered irreducible by adliesions, many more become so from the
cause above mentioned.
A TREATISE ON RUPTURES. SH
In the sac of old omental ruptures that have been long down,
and only suspended by a bag truss, it is no very uncommon thing
to have a pretty consiilerable quantity of fluid collected: this, in
different states and circumstances of the disease, is of different
colour and consistence, and seldom so much in quantity as to oc-
casion any particular attention to it; but on the other hand, it
sometimes is so much in quantity as to become an additional dis-
ease to the original one. I have more than once been obliged to
let it out, in order to remove the inconvenience arising from its
weight, and the distention of the scrotum, which I have also seea
become gangrenous by the neglect of this operation.
If the hernia be of the intestinal kind merely, and the portion
of gut be small, the risk is greater, strangulation being njore like-
ly to happen in this case, and more productive of mischief, when it
has happened: for the smaller thi? portion of gut is which is engaged,
the tighter the tendon binds, and the more hazardous is the conse-
quence. I have seen a fatal gangrene, in a bubonocele, which
had not been formed forty-eight hours, and in which the piece
of intestine was little more than half an inch. There are few
practitioners who have seen business, but know the truth of this;
but perhaps the reason -of it is not sufficiently explained to the un-
knowing. It is this: when a considerable portion of intestine
passes out from the belly in a hernial sac, it necessarily and un-
avoidably carries with it a proportional quantity of the mesentery,
which every body knows is a strong doable membrane. When
the prolapsed part is at all considerable, this double membrane is
again in some measure folded on itself, and lakes off a good deal
of the effect of the stricture on the intestine. Now, although this
circumstance will not prevent the effect, if the means of relief be
totally neglected, yet it will most certainly retard the evil, and
give more time for assistance; whereas, when there is little
or none of the mesentry got through the tendon, and the thin, ten-
der intestine bears all the force of the stricture, it is immediately
brought into hazard.
The practical inference to be drawn from hence is loo obvious
to need mentioning.
In the intestinal, as in ihe omental hernia, they which have been
often or long down, are in general more easily returned, and do
318 A TREATISE ON RUPTURES.
not require such immediate assistance, as they which hate seldom
been down, or have recently descended; and in the one i<:ind of
hernia as well as the other, the state of the hernial sac with re-
gard to size, thickness, &c. depends very much on the date of the
disease, and the regard that has been paid to it.
If ihe hernia be caused by a portion of the intestine ileum only,
it is in general more easily reducible than if a part of the colon
has descended with it, which will also require more address and
more patience in the attempt. The reduction of a mere intestinal
hernia loo, cceleris paribus, will always remain more practicable
than that of a mere ouienlal one, after it has attained to a certain
size and state, as the part contained within the former is lia-
ble to less alteration of form than that within the latter; which
alteration has already been mentioned as no infrequent hinderance
of the return of an old caul rupture.
Not that the parts within a mere intestinal hernia are absolute-
ly exempt from such an alteration as may render their return in-
to the belly impracticable, even where there is no stricture: for I
have seen that part of the mesentery, which has lain long in the
neck of the sac of an old rupture, so considerably hardened and
thickened, as to prove an insuperable obstacle to its reduction.
Upon the whole, every thing considered, I think it may be said,
that an intestinal rupture, is subject to worse symptouis, and a
greater degree of hazard than an omental one, though the latter
is by no means so void of either as it is commonly supposed to be;
that bad symptoms are more likely to attend a recent rupture than
one of ancient date; that the descent of a very small piece of in-
testine is more hazardous than that of a larger; that the hernia^
which coHsisis of gui on^y, is in general attended with worse cir-
cumstances than thai which is made up both of gut and caul; and
that no true judgment can be formed of any rupture at all un-
less every circuiv;staiice resating to it be taken into consideration.
The cure of a rupture is either perfect, (called also radical,) or
imp<Mlect, which is called pailiaive.
This disiincUon whi.h is jusi and true, and founded both on
reason and experience, has frequently been misunderstood by the
A TREATISE ON RUPTURES. 319
generality of mankind, and has therefore been the cause of much
undeserved censure on the practitioners of surgery.
The truth is, that though the events are extremely different, yet
the chirurgi al means which are made use of in either case are
exactly the same, viz. redciclion of the protruded parts, and reten-
tion of them when so reduced by proper bandage: these sometimes,
and in some circumstances, produce a perfect cure; at other times,
and under other circumstances prove only a palliative one; and this
uncertainty of events being dependent.on causes which a surgeon
can neither foresee nor direct, with any tolerable degree of cer-
tainty, should warn him against being too forward in making a
promise.
To those who are ignorant of the anatomical structure and dis-
position of the parts concerned in the disease, this assertion has
the air of a paradox: they naturally suppose that the means which
are or should be made use of to obtain a radical or perfect cure, are
or ought.to be different from those used toward obtaining only a
palliative one; and in this mistake they are confirmed by the bold,
though false, assertions of all rupture-quacks.
To labour under a troublesome disorder, perhaps in the most
joyous and active part of life, is very disagreeable: to be told that
a palliative cure, by the constant use of the truss, is all that can
reasonably be expected, gives small comfort, and renders the in-
sinuation, that the regular professors of surgery do not understand
the proper treatment of this disease credible, or at least makes it
be believed: quodvolumus^facik credimus. Ignorance of the true
nature of the disorder, with a strong desire to be well, on the side
of the patient, and bold plausible promises on the side of the pre-
tender, encourage the delusion, till time, and the continuance of
the rupture, prove the fraud^ which few are found ingenuous enough
to own. Whether it proceeds from a false bashfulness, which
makes a man be ashamed of acknowledging that he has been im-
posed upon; from a desire merely to conceal the disorder; from
a pleasure arising from seeing others deceived as well as them-
selves; or from a much worse cause than either of these, I know
not: but it happens not very infrequently that the patient, though
perfectly undeceived, and convinced of the imposition, concurs in
propagating the delusion, and asserts that he has received a cure,
which he knows he has not. Of this I could produce many
S20 A TREATISE ON RUPTURES. ,
instances, and some of those among people of such rank, as one
would expect should set them above such disingenuousntiss.
I have already said, that to replace the prolopsed body, or
bjodies, within the cavity of the belly, and to prevent their failing
out again, by means of a proper bandage, is all that the ari of
surgery is capable of doing in this disease: and what I said was
strictly true. But it must also be remembered, that nature, ac-
cording to the age of the patient, the date of the disease, the kind
of rupture, and some other circumstances, is often capable (when
properly assisted, and not obstructed) of doing more, and of con-
firming that as a perfect cure in some, which in others she leaves
imperfect, and constantly requiring the assistance of art: for when
the portion of gut or caul, or whatever formed the tumor, is per-
fectly and properly replaced in the belly, and an opportunity there-
by given to the aperture in the tendon to contract itself, and for a
proper bandage to bring the sides of the entrance of the hernial,
sac as near together as it will admit, the surgeon has really done
his part. What remains is that of nature: and whether she will
be capable of so contracting the part, as to prevent a future de-
scent or not, is matter of great uncertainty: it is a circumstance
which art has very little power of assisting, and which can be
known only from the event.
On the contrary, all the pretensions which have at difierent
times been made to remedies, indued with the capacity of healing
and consolidating the parts supposed to be broken or torn, or of
constringing such as are dilated, have all proved inefficacious and
delusive, to say the best of them: the parts concerned in this
disease, and which ought to be affected by the operation of such
remedies, are absolutely out of the reach of any applications or
medicines whatever: the relief which some people have found
while under such processes, has been from the long rest which they
have been subjected to, or from the strict bandage which has been
put upon them: either of which will, in some cases, do a great
deal; while the remedies which are either applied or taken, are
made use of merely to deceive, and never had, or can have, any
share in the real cure of a rupture.
By what has been said, I must beg not to be understood to
mean, that when the gut or caid have been once replaced, the
A TREATISE ON RUPTURES. 321
patient can receive no farther benefit from chirurgical assistance;
nor that every rupture in persons of mature age is incapable of
perfect cure: this is far from my meaning, and far from truth.
There are many circumstances attending ruptures, which will
require frequent assistance in order to render a cure more pro-
bable; and there are many ruptures in persons of mature age,
which will admit of perfect cure, if properly and judiciously
managed from the first.
I only mean to contradict that positive assertion which all rup-
ture-quacks make use of, and which too many of mankind believe,
viz. that there are medicines and applications which are specific in
the cure of. this disease, and that they (such quacks) are possessed
of them; both which are absolutely false.
As this is a matter of some impjortance to mankind, and may
possibly be rendered still more intelligible by a few words, I beg
leave to be indulged in them.
The general doctrine is, that the ruptures of infants, and of
very young children, frequently admit of a perfect cure; those of
adults less frequently; and those of old people seldom or never; all
which, with certain limitations, is true.
The great and material difference between these consists in the
state of the hernial sac, and that of the aperture in the abdominal
tendon through which it passes.
The sac of a hernia has already been described as being an
elongation or process of the peritoneum, or general lining of the
cavity of the belly, thrust down before the body constituting the
swelling; which body is enveloped in it as in a bag, somewhat
resembling what is vulgarly called a thumb-stall, or the finger of
a glove cut off. While the hernia is recent, this bag is thin and
fine, like the rest of the membrane of which it is a portion; and
being of a very dilatable nature, is easily enlarged, according to
the quantity of contents which insinuate themselves into it: like
some other parts of the body, it increases in thickness and tough- ,
ness as it increases in capacity; and as it seldom if ever returns
back into the belly, after it has once passed out from it, it is by
the repeated descents of a portion of gut or caul into it, gradually
enlarged in size, and consequently in thickness; insomuch, that
in old ruptures that have been neglected, or deemed irreducible,
VOL. I. s s
3^2
A TREATISE ON RUPTURES.
or been suffered to remain long, or always down, it generally ac-
quires a very considerable degree of toughness, thickness, and
hardness. In those ruptures which are not of the congenial kind,
at first it gets no lower than the groin, and while it remains there
is generally small and thin; but by frequent protrusions of the in-
testine or omentum, it is pushed by degrees into the scrotum, and
then most frequently acquires a pyriform kind of figure, having
its broader part in the scrotum, and its narrow one, or neck, in
the groin.
|n infants, in very young subjects, and in recent cases, this sac,
from its soft thin state, is capable of having its upper part or neck
So compressed by means of a bandage, as either to procure an
union of the sides with each other, or at least so to lessen the dia-
meter of its passage as to prevent the descent of any thing into it
from the belly: this produces what is commonly called a perfect
cure.
In those of mature age, or whose ruptures are of some stand-
ing, the entrance into the sac is generally large, in proportion to
the size and age of the patient, and thicker and firmer than in the
former state, for reasons just given: in these, therefore, the closing
or compression of its neck, enough to hinder the falling down of
any thing from the abdomen, is more difficult to accomplish, and
more unlikely to succeed. In very ancient people, or very old
ruptures, success is still more improbable, for the same reasons.
A bandage therefore, or truss, though it is the only remedy at
all ages, and in all states of reducible ruptures, yet acts in a dif-
ferent manner, and is capable of producing very different effects,
according to the circumstances of the cases in which it is applied:
in very young persons a radical cure is frequently the conse-
quence; in the middle aged it often gives the tendon and mouth
of the sac such opportunity of being contracted, as to produce
nearly the same event; but as it only serves by the mere pressure
of the pad to keep the parts in their proper place, in very old
people it can hardly ever be laid aside, without hazard of a new
descent, which, while it is worn properly, it will almost always
prevent.
From the foregoing short account, the following facts may, I
think, be collected: —
A TREATISE ON RUPTURES. 323
1. That the principal circumstances attending a rupture ixiust
be subject to great variety, according to the age and constitution
of the patient, the date of the disease, &c. and consequently that
the precise case, and age, in which a radical or perfect cure is
obtainable or not, is not easy to be determined, though a judicious
man will most commonly know when it is very improbable.
2. That recent ruptures, if immediately and properly taken
care of, are capable of a perfect cure at almost any age.
3. That though the thickness of the hernial sac, and the large-
ness of the abdominal aperture, are generally mentioned as the
two causes why old ruptures do not admit of a cure, yet in fact
the latter is only a consequence of the former.
4. That all external applications in the attempt toward the
cure of a rupture, must, if they are used with any design at all,
be intended eiUier to constringe the aperture through which the
parts have descended, or to lessen or contract the diameter of the
neck of the hernial sac.
5. That the construction of the tendinous aperture (supposing
such medicines could penetrate to it) is impossible while it con-
tinues dilated, by an old, thick, tough hernial sac, which sac, from
the connections it always has- with the cellular membrane of the
spermatic chord, can never be returned into the belly; and there-
fore,
6. That such medicines can be serviceable no other way than
by rendering that sac again thin, fine, and compressible; which,
from the nature of things, and from all experience, is absolutely
impracticable.
SECT. II.
The different treatment which ruptures may require, being de-
pendent on different circumstances attending the disease, I shall,
for the better information of the inexperienced reader, divide them
into four classes; under which, I think, may be comprehended
not only all the kinds of hernias, but every particularity also
with which they may happen to be distinguished.
324 A TREATISE ON RUPTURE'S.
1 . Under the first, I reckon those which are capable of easy
and immediate reduction, and are not attended by any trouble-
some or bad symptoms.
2. Under the second, those which have been so long down,
that the contained parts are either so altered in form, or have con-
tracted such adhesions and connexions, as to be absolutely inca-
pable of being reduced at all.
3. Under the third, I comprehend those in which such stric-
ture has been made on the protruded parts, as to bring on pain,
and produce such an obstruction in the intestinal canal, as to ren-.
der immediate reduction necessary, but at the same time difficult.
4. And under the fourth, I shall place those in which the re-
turn of the parts by the mere hand is absolutely impracticable,
and in which the patient's life can be saved only by a chirurgical
operation.
The first is very frequently met with in infants, and sometimes
in adults, and is too often neglected in both. In the former, as
the descent seldom happens but when the infant strains to cry,
and the gut is either easily put up, or returns sud sponte^ as soon
as the child becomes quiet; it often is either totally unattended to,
or an attempt made to restrain it only by a bandage made of cloth
or dimity, and which, being ineffectual for siich purpose, lays the
foundation for future trouble and mischief.
This is in great measure owing to a common opinion, that a
young infant cannot wear a steel truss: a generally prevailing
error, and which ought to be corrected. There is no age at which
such truss may not be worn, or ought not to be applied; it is,
when well made, and properly put on, not only perfectly safe and
easy, but the only kind of bandage that can be depended upon;
and as a radical cure depends greatly on the thinness of the her-
nial sac, and its being capable of being so compressed as possibly
to unite, and thereby entirely close the passage from the belly, it
must therefore appear to every one who will give himself the trou-
ble of thinking on the subject, that the fewer times the parts have
made a descent, and the smaller and finer the elongation of the
peritoneum is, the greater the probability of such cure must be.
The same method of acting must for the same reasons be good
in every age in which a radical cure may reasonably be expected;
A TREATISE ON RUPTURES. 325
tliat is, the prolapsed parts cannot be too soon returned, nor too
carefully prevented from falling down again, every new descent
rendering a cure both more distant and more uncertain.
As soon as the parts are returned, the truss should be imme-
diately put on, and worn without remission, care being taken, es-
pecially if the patient be an infant, to keep the parts on which it
presses constantly washed, to prevent galling.^
It- can hardly be necessary to say that the surgeon should be
careful to see that the truss fits, as his success and reputation de-
pend on suchxare. A truss which does not press enough is worse
than none at all, as it occasions loss of time, and deceives the pa-
tient or his friends; and one which presses too much, or on an im-
proper part, gives pain and trouble, by producing an inflamma-
tion and swelling of the spermatic chord, and sometimes of the
testicle.
In adults, whose ruptures are of long standing, and accustomed
to frequent descent, the hernial sac is generally firm and thick,
and the aperture in the tendon of the abdominal muscle large;
the freedom and ease with which the parts return into the belly,
when the patient is in a supine posture, and the little pain which
attends a rupture of this kind, often render the persons who la-
bour under it careless: but all such should be informed, that they
are in constant danger of such alteration in their complaint, as
may put them into great hazard, and perhaps destroy them. The
passage from the belly being open, the quantity of intestine in the
g As the constant and unremitted wearing a truss to some people is Irksome
and inconvenient, it may not be improper to remark that Mr. Pott did not
Intend by the expression " worn -without remission," that the truss is always to
be worn, by night as well as by day ; he generally allowed it to be taken off
when in bed, as a recumbent posture, in most cases, is sufficient security
against the reprotrusion of the intestine or omentum ; but the truss should
be carefully re-applied in the morning, while the person is in the same hori-
zontal position, and either he, or she, should be particularly observant to put
it on when under the necessity of going to stool in the night. If the patient be
subject to fits of coughing, common sense dictates that at those times it ought
not to be laid aside. Children are so subject to violent exertions from crying
and other causes, that their trusses cannot often be safely left ofT; but when
they are well and quiet, and in bed, the pressure may now and then be ju-
diciously dispensed with ; and the removal of it, though but for short inter-
vals, affords them great ease and relief E.
336 A TREATISE ON RUPTURES.
bernial sac is always liable to be increased, and, when down, to
be bound by a stricture. An inflammation of that portion of the
giit which is down, or such obstruction in it as may distend and
enlarge it, may at all times produce such complaints as may put
the life of the patient into imminent danger; and therefore, not-
withstanding this kind of hernia may have been borne for a great
length of time, without having proved either troublesome or
hazardous, yet, as it is always possible to become so, and that
very suddenly, it can never be prudent or safe to neglect it.
Even though the rupture should be of the omental kind, (which
considered abstractedly is not subject to that degree or kind of
danger to which the intestinal is liable,) yet it may be secondarily,
or by accident, the cause of all the same mischief; for while it keeps
the mouth of the hernial sac open, it renders the descent of a
piece of the intestine always possible, and consequently always
likely to produce the mischief which may proceed from thence.
They who labour under a hernia thus circumstanced, that is,
whose ruptures have been generally down while they have been
in an erect posture, and which have either gone up of themselves,
or have been easily put up in a supine one, should be particularly
careful to have their truss well made, and properly fitted; for the
mouth of the sac, and the opening in the tendon, being both large
and lax, and the parts having been used to descend through them,
if the pad of the truss be not placed right, and there be not a due
degree of elasticity in the spring, a piece of intestine will, in some .
posture, slip down behind it, and render the truss productive of
that very kind of mischief which it ought to prevent.
It is scarcely credible how very small an opening will serve
for a portion of gut or caul to insinuate themselves into at some
times. Now, though in persons of mature age it most frequently
proves impracticable so to compress the mouth of the hernial sac,
as absolutely to close it, yet, by the constant use of a well-made
truss, it may be so lessened, as to render the descent of a piece of
intestine into it much more difficult: from whence we may learn
the great consequence of having the part completely reduced be-
fore the truss is applied, and the danger that may be incurred by
laying such bandage aside after it has been worn some time; since
the same alteration which renders the descent of the gut less easy.
A TREATISE ON RUPTURES. SS*/
will also make the reduction more difFicult, if a piece sboiikl hap-
pen to get down: and hence also we may learn why the bandage
should be long and unremittingly worn by all those whose time of
life makes the expectations of a perfect cure reasonable, many of
the ruptures of adults being owing to the negligent manner in
which children at school are suffered to wear their trusses.
I know a gentleman who has for some years had an omental
rupture, which was neglected while he was young, and he having
naturally a lax habit, and the abdominal opening being much di-
lated, he finds it extremely difficult to keep it up, even with the
best truss he can get, behind which it will sometimes slip down:
when this happens, it gives him such immediate and acute pain
at his stomach, and makes him so intolerably sick, that he is
obliged immediately to throw himself on his back, and procure
the return of the piece of omentum.
SECT. III.
In the second class I ranked those cases in which the parts con-
stituting the hernia are found irreducible, but not in a state of in-
flammation, nor producing any troublesome or dangerous kind of
symptoms.
This incapacity of reduction may be owing to several causes,
but most frequently arises either from the largeness of the quan-
tity of the contents, from an alteration made in their form and
texture, or from connexions and adhesions which they have con-
tracted with each other, or with their containing bag.
I have already mentioned it as my opinion that ruptures are
sometimes rendered difficult to be reduced, by that portion of the
intestinal canal which is called the caecum, or the beginning of
the colon, being contained in the hernial sac. Of which fact I
am as much convinced as the nature of such kind of things will
328 A TREATISE OjST RUPTURES.
permit; that is, by observations made both on the living and the
dead.
When a hernia of this kind {viz. one containing such a part of
the intestinal tube) has been long neglected, and suffered to
remain in the scrotum without any bandage at all to support its
weight, the hernial sac, being constantly dragged down, and kept
in a state of distention, necessarily becomes thick, hard, and
tough: by this means the diameter of its neck is lessened, and the
return of the intestine back from the scrotum into the belly ren-
dered more and more difficult, as the parts through which it is to
pass become harder, and less capable of yielding. This will,
indeed, in time prove an obstruction sufficient to hinder any part
of the intestine, or even of the omentum, from being returned:
but the more the difficulty is, which proceeds from the mere
figure and size of the portion of gut, the greater" will be the ob-
struction when added to that arising from the just mentioned
cause.
An alteration produced by time, and constant, though gentle,
pressure in the form and consistence, or texture of the omentum,
is also no infrequent cause, why neglected omental ruptures be-
come irreducible.
The cellular membrane in all parts of the body, however loose
and light its natural texture may be, is capable of becoming hard,
firm, and compact, by constant pressure. Of this there are so
many, and so well-known instances, that it is quite unnecessary
to produce any.
The omentum, from its texture, is liable to the same conse-
quence. When a portion of it has been suffered to remain for a
great length of time in the scrotum, without having ever been
returned into the belly, it often happens, that, although that pai't
of it which is in the lower part of the hernial preserves its natu-
ral soft, adipose, expansile state, yet all that part which passes
through what is called the neck of the sac, is, by constant pressure,
formed into a hard, firm, incompressible, carnous kind of body,
incapable of being expanded, and taking the form of the passage
in which it is confined; exactly filling that passage, and rendering
it impossible to push up the loose part which fills the scrotum.
4. TREATISE ON RUPTURES. 399
The same le.son ft,- incapacity of reduction is also sometimes
p.oduccl „„ il.atpart of .l,e mesenlc-y which has been suffered to
i- q .et or a great length of time in the neck of an old hernial «,
1 eot er ,mped,men., which 1 mentioned, to the re.,,™ of o d
or , tHrr" ""' ^.'"'^''■'"■"'•*= P-''^ either with each
,1 i ;.° , ' "' ""'S ""'=""'"S "'™- I'l'- i» co,nmon to both
trr fte:r\;;,-;:r"^''^ ^"»"'" ->■
iii cou.aet „; h , .' "' ''''" Pe'-»ii'le<l '0 lie long
co.na<,t only. These adhesions are more or less fi-m in
^tfcent cases, but even the slightest will almost ahvas be fod
Many, or perhaps most of these irreducible ruptures be-ome
relief IJ, ' 7' T '"'° ""^ ^'"'^' *'^ ^^^ capable of „o
scrotLj '"—.ence arising from the tveigh. of the
People in this sitaalion should be particularly careful not ,.
-akea,,yattemp,s beyond their s,re„g.h^orai.„S;:„
t:7:::^:^\::;:;-^^^:^ - -o-d scr„.um, a:^ :
whe,. the tumor is4tgtt:kieT;:::;tst
^ I am not unaware that most of these are can.M. r u •
operation for the bubonocele as it :7^!]i 1 T ^^'''^ ^'"'"^ °J'th«
p.-oposi„ff it in any caseTn vLich the ' ' ' " ' ''""''^ "^^^^- ^^^"^'^ °f
life of thepatient so M^^rn . "'' "«^ ^^^^P^^n^s that threaten the
I also a. nit una ^ s d Jh. S""^' '' '" ^^^ P'^^ - ^ -cans of cur.,
sort has had on theunknolw u i^ Vf "' 'P^"^'°" °^ *^« ^^ ^^is
J.ave emboldened tiie me ope, a or o c"" "' "'^^ -cidental successes
dors, in simibr cases; and that C til .f' "^^^'^ ^'-" -^ "^"two mur.
i-"pture.doclors h.v - ^iVtrStZ T. T' °^ '"'^'"^' ^^'"^ ^^ '^ese
han-^ed. ^ '"^^^- '^ ^^^^"^'^'^' «'J^en they ought to have beer-
VOL. I.
9 t
aofl A, TKEJTISE ON KUPTUKES.
,vora at ll.e boUom of the cuspemovy to prevent exeorialion, anci
le c otum »1.0'<1'1 te frequently vvashe.1 for tl,e same r.ason; a
s of ski,, i„ this part, and in sael, circmstances, be.ng some-
e:„ftl,e.,.,rrost'l,„portance, Ti«y o„g„t also to e paH.c.
larlv attentive to the office of the inles.inal canal, to see Ihat they
:,y: any irregularity of diet disorcler it and Keept^-clve
from being costive, for reasons too obv.ous to "«'";" -^^f/,
these means, and with these cautions, many FOP'^ ' » ^ /"^'f,
their lives for many years free from d.sease or compla.nt, «,th
trprv Invo-p irreducible ruptures. .
6n th°e ler hand, it is fit that mankind should be appr,sed
thatthe ,uiet, inoffens.ve state of thiskind of hernia . by no n.a,.
to be depended upon; many things may happen to ,t b "h h
„ay be so altered, as to beconre haza,-dous, and even fatal, a,, ,
flammation of that part of the gut which is down, any -^s ruct^, to
ttepassage of the aliment or f^ces through it, a s.ncture made^
b^t abdominal tendon, either on what ha, been «»S ow ,
on a new portion which may at any t,me be added to .t a e a
°vays capable of so altering the state of the case, as to put thehfe
of the patient into clanger. ^
ndeed, the hazard arising from a stricture made on a p.ece of
inte fme ontained in the sac of an old irreducible hernra, ,s ,n one^
epg eater than that attending one that has bee,, found at., me
due lie- since fro,r. the natu,-e of the case it w,l hardly adm,t
oftny tLmpt toward relief but the operation, and t a, ,n these
cL^Ltcesmust necessarily be accompanied w,th add,t,o„al
difficulty.*
T.-.-,rP,1 to be i^resent at the opening of a dead body
; I was some time ago desired to be pi c.et. i,,.educible lievnia,
„/ a man who h.d ibr many years labo.,red ^ ;; ^f ' :,,, ,.„, u.
,ut .hlch had never ^-^^^^^:X:':^^,:^Zm.o. permit me
weight, and who died very old: m '^'l^J''}^^' .entleman, Mr.
,0,0, but I desired leave ^<^ ^^^^ ^^^^^Z^:^ ^^A;,.. settled in
rrice, who was then my pupil at St. Ba.tholumcvv^
Wales. The following is the account h. gave me : _^^ ^^^^^^^^
.. The hernia was of fourteen years s andn_,g, ^"'"^ '" ^ ,„a dis-
I fr,,. ;(<; vprhirlion : it was on tne iigni si^'<-.
«had ever been made foi '^J'^^^f'"" measured, from the opening m
<= tended the scrotum to such a s,ze, thaUt measu, e ^_^^^ ^^_^
» the abdominal muscle to the bottom of he ^ - ' ^ 0 u ^^^^ ^^^^
. Ulf. and round the tumor ^^^-y^^;;::^':^^:^., .„ thick as might
:;;rL:::;:t:s--^-- -- -ie^unumdeum.. sac
A TREATISE ON RUPTURES. 531
Among the ruptures which liave been thought not reducible,
and treated as such, there have been some, which, upon more judi-
cious and more patient attempts, have been found capable of re-
duction.
When this is suspected to be the case, the proper method is by
absolute rest, in a supine posture, for a considerable length of
lime, by great abstinence, and (he use of evacuants, so to lessen
the size of the parts in the hernial sac as to render them capable
of passing back again into the belly.
This method has now and then succeeded, and in some cases
is worth the trying; but previous to the attempt, there should be
some circumstances which makes success probable; and there
should also be good reason to believe, that the habit and age of
the patient will bear the necessary confinement and evacuiUion;
otherwise, even though he should get rid of his rupture, he may
be much worsted by the experiment^
If such attempt succeeds, a truss should be immediately put on,
and worn constantly, without remission; for in these people, the
largeness of the abdominal aperture, the thickness of the hernial
sac, and the relaxation of the mesentery, make a new descent al-
ways to be apprehended and guarded against.
An omental rupture which has been so long in the scrotum as
to have become irreducible, is very seldom attended' with any
bad symptoms, considered abstractedly: but, as I have already
said, it is constantly capable of being the occasion of an intestinal
hernia, and all its consequences; neither is that aH, for the omen-
" of the colon, called the cscum, with its apper.dicula vermiformis, tog-ether
" with a Lirge portion of omentum, were tlie contents ; the duodenum was so
"displaced by tlie weiglit of the rest of the guts within the sac, tiiat its direc-
" tion from the pylorus was perpendicular ; the caul adhered to the hernial
"sac in several places, the intestine in none; the testicle, included in its tu-
" nica vaginalis, was much wasted ; the spermatic artery and vein ran down
" behind the hernial sac, but the vas deferens ran up on the inn.n- and left
" side of it, at a gresit distance from them, through the whole of its course ;
" but nevertlieless would not have been in the way of the operation had it
"been necessary."
t Hildanus gives an account of a man radically cured by six months' con-
finc-mcnt to bed, in the case of a rupture of twenty years date.
• Garengeoi relates the case of an epiplocele producing very bad symptotnS;
andso doesDionis.
332 A TREATISE ON RUPTURESu
turn, either so altered in form and texture, or so connected as to be'
incapable of reduction, may by accident inflame, and either be-
come gangrenous or suppurate, and be the occasion of a great deal
of trouble. Of this I have seen two or three instances, one of
Tvhich I will relate.
I was desired to see a gentleman, from whose scrotum near a
pint of brown, sanius, fceted fluid had been discharged two or three
days before. The account he gave of himself was as follows:
That he had been from his youth subject to the descent of a soft,
flabby body into the scrotum, when he was in an erect posture,
but which for many years he could put up when he pleased, and
which always went up when he lay down; that having no trouble
from it, and being naturally shy and bashful, he had done nothing
to it, nor showed it to anyone; that from the sudden spring of an
unruly horse, he had struck it with great violence against the pum-
mel of his saddle, which had given him immediate pain; that the
next day it swelled still more, and became more painful, but
that being afraid, or ashamed, he still concealed it, and only
anointed it with something greasy, till at last he could bear it no
longer: the person to whom he showed it took it for a hydrocele,
tapped it, and let out the fluid just mentioned; and on the fifth or
sixih day from this operation I saw it.
The whole scrotum was much inflamed, and the orifice made
by the trocar foul and sloughy: he had a degree of heat and fever
upon him, which forbad any operation at that time; and therefore
I desired that he might be dressed soft and easy, have an emollient
cataplasm applied to the whole scrotum, lose some blood, and have
a clyster. »
By proper care the tumor subsided, his fever left him, and the
slough casting off" largely brought the putrid omentum within view;
upon sight of which I would have laid the whole open, but was
not permitted. I enlarged the orifice a little, and in so doing cut
through an old hernial sac, which was very thick and hard; what
part of the omentum was loose I brought away with a pair of for-
ceps; but the separation of the whole took up much time, and the
bard hernial sac caused so many abscesses, and occasioned so large
a discharge, that, being a valetudinarian, he had certainly sunk
under it, had it not been for the free use of the bark.
A TREATISE ON RUPTCREa. 33J
If, instead of this method of treating it, I had been permitted to
imve laid ,t open through the whole of its length, r<3moved the
roUen Oinentum, and cut off some part of the sides of the hernial
sac, the cure would have been shortened, and the scrotum, would
have been left in a much better state.
That an omental rupture, which has so long resisted all attemp's
for reduction, as to create a belief of its being absolutely irreduci-
b e, maj now and then, by long rest and abstinence, become capa-
ble of bemg returned, lam under no doubt, for reasons whirb
i^ave already been mentioned: and not long ago, I had myself a
patim^t in St. Bartholomew's hospital, who underwent the opera-
tion for a radical cure of a hydrocele, who had also an omental
iierma, wh.ch I and some others had often tried ineffectually to
reuuce: this, during the time of his confinement to bed after the
operatmn, went up of its own accord, and was ever afterwards
kept there by a truss.
It sometimes happens in old compound ruptures, that the piece
of mtestme is reducible, and that of the omentum is not; in which
case we are told, that the portion of intestine should be kept up by
a truss whose pad may be so made, as not to press on the omen-
turn whde it restrains the intestine.
I will not deny that this may now and then be practicable, but
It ,s not often so, and it ought to be particularly attended to, and
very carefully watched, lest a small piece of gut slip down, and
being pressed on by the truss, produce fatal mischief ' '
I have seen an omental rupture, in which the piece included In
the sac had the knotty hardness, the pain, and every other svmp-
torn of a cancer. * '
SECT. IV.
Under the third division I reckon those ruptures which are
reducible, but whose reduction is difficult, and which are attended
with pam and trouble and hazard.
^ Difficulty of reduction may be owing to several causes. Thr
size of the piece of omentum, or the inflamed state of it; the quaa-
S34 A TREATISE ON RUPTURES.
tity of intestine and mesentery; an inflammation of the gut or its
distention bj fjEces or wind; or the smallness of the aperture of
the tendon through which the hernia passes. But to whatever
cause it be owing, if he prolapsed body cannot be immediately
replaced, and the pa.ient suffers pain, or is prevented thereby from
going to stool, it is called an incarcerated hernia, a strangulated
hernia, or a hernia with stricture.
The symptoms are a swelling in the groin or scrotum, resisting
the impression of the fingers: if the hernia be of the intestinal
kind, it is generally painful to the touch, and the pain is increased
by coughing, sneezing, or standing upright. These are the very
first symptoms; and if they are not relieved, are soon followed by
others, viz. a sickness at the stomach, a frequent reaching or incli-
nation to vomit, a stoppage of all discharge per anum, attended
with a frequent hard pulse, and some degree of fever.
A patient in these circumstances may be looked upon as in some
danger, and requiring immediate assistance. A stricture made on
the prolapsed part of the gut, by the borders of the natural aper-
ture in the tendon of the oblique muscle, is the immediate cause
of these symptoms, which nothing can appease or remove, except
what will take off that stricture. This can be accomplished only
by removing the part so bound from the tendinous opening; that
is, by returning it back into the belly whence it came; or by
dividing a part of the tendon itself: the former of these, when it
can be practised, is always most eligible, and makes our present
subject.
I have already observed, that a portion of intestine, while it is
neither bound by any degree of stricture, nor affected by inflam-
mation, will remain quiet in a hernial sac in the scrotum, and
perform its proper office freely and perfectly; but the instant
either of the above-mentioned accidents (particularly the former)
happens, the case is altered; the passage both of the aliment and
fajces is stopped or interrupted; the peristaltic motion of the whole
canal is disturbed or perverted; and the circulation of the blood,
through the straitened portion of intestine, is so imj)eded, that
if the obstruction is not removed in time, a mortification must
follow.
Every symptom which attends an incarcerated rupture depends
A TREATISE ON RUPTURES. 533
on this cause, and is jusdy accountable for from it. The tumor,
the pain, the tension of the belly, tiie nausea, the vomiting, and
the suppression of stools, are so many effects produced by it, and
removeable only by removing it.
My present consideration being those ruptures which are capa-
ble of being returned, I am now to speak of the manner of at-
tempting such reduction.
The patient should be laid in a supine posture, with his trunk
certainly as low, if not lower, than his thighs; the thigh on the
diseased side should be so elevated, as to contribute as much as
possible to the relaxation of the abdominal aperture; and then the
surgeon grasping the lower part of the tumor gently wiih his hand,
in such a manner as to keep the testicle from ascending, and the
intestine from descending, must endeavour to procure the return
of the latter through the ring, as it is vulgarly called, by gentle
continued pressure toward that opening. If the case be a bubono-
cele, there will be no occasion for endeavouring to grasp the tu-
mor, but by continued, moderate pressure on it with the fingers,
to endeavour the return of the piece of gut.
This may serve for a general description of the method of per-
forming this operation; but the exact manner of executing it is one
of those manoeuvres which can be learnt only by observation and
practice, and of which no verbal description can convey an ade-
quate and perfect idea: knowledge of the structure and situation
of the parts, will instruct any one how to go about it, and a little
practice will soon make him adroit.
The posture of the body and the disposition of the lower limbs
may be made very assistant in this operation, when the difficulty
is considerable; the nearer the posture approaches to what is com-
monly called standing on the head, the better, as it causes the
whole packet of small intestines to hang, as it were, by the stran-
gulated portion, and may thereby disengage it. A little time and
pains spent in (his manner will frequently be attended with suc-
cess, and obtain a return of the part; but if it should not, and the
handling of it (which I must repeat should always be gentle) be-
comes painful, and very fatiguing to the patient, we are advised
to desist a fen^ hours, and try the effect of other means.
^36 A TREATISE ON RUfTURES.
These means are phlebotomy, clysters, cathartics, the applica-
tion of cataplasms, fomentations, embrocations, &c.
Children, especially very young ones, bear the loss of blood
very ill, and are very apt to swoon, if the quantity be at all con-
siderable; if, therefore such accident happens, the surgeon should
embrace the opportunity which such general relaxation will afford
him of reducing the rupture, especially as it gives him another
advantage, by preventing the child from crying, and making re-
sistance.
Perhaps there is no dis^ease affecting the human body in which
bleeding is found more eminently and immediately serviceable
than in this, and which therefore, if there are no particular cir-
cumstances in the constitution prohibiting it, ought never to bft
omitted; but, on the contrary, should be freely and largely re-
peated, if it appears at all necessary.
A semicupium, or warm bath, will, by the general relaxation
which it necessarily produces, be found frequently serviceable.
The use of warm fomentations, soft cataplasms, and relaxing
oily embrocations, are also advised with a view to relax the ten-
don of the abdominal muscle, and to render the return of the
parts contained in the hernial sac easy; but I am afraid that such
kind of applications have in general been the occasion of much
more mischief than good. The effect of them can hardly reach
beyond the skin and membrana cellularis, and may possibly, by
relaxing them, take off some small part of the pain which arises
from their distention, but will seldom have any effect on the im-
mediate seat of the disease, the tendon of the oblique muscle: the
enlargement or relaxation of which only can be of material ser-
vice.
I know that in this I differ from the majority both of writers
and practitioners, but having (as I think) truth on my side, I do
again venture to say, that I verily believe, that the confidence
which has been placed in such kind of applications has destroyed
many more lives than it has saved. A hernia, with painful stric-
ture, and stoppage of stools, is one of those cases in which we
can seldom stand still, even for a short space of time; if we do
not get forward, we generally go backward; and whatever does
no good, if it be at nil depended upon, certainly docs harm, by
A TREATISE ON RUPTURE S% -337
occasioning an irretrievable loss of time: of this kind I take the
cataplasm and embrocation™ to be. While the former is applied,
or the latter used, no other more powerful means are made use of;
and though it has the appearance of doing something, yet I fear
it is little more than specious trifling; especially if the case be at
all pressing.
Very different have been the opinions of different people con-
cerning the use of cathartic medicines; some advising them strenu-
ously, others placing no dependence on them at all. As different
also have been the opinions of those who do advise them, with
regard to the kind of medicine proper on this occasion; some pre-
scribing those of the lenient kind, such as Glauber's salt, infusum
sennae, &c. others the more powerful or ponderous kind of reme-
dies, such as Extract. Cathart. Jallap, Mercurius dulcis,'»&c.
I believe I may venture to say that I have tried them all, but I
cannot say that I have such faith in any of them as to think very
highly of them. With regard to the former, viz. the lenient sort
of purges, it is not often that a patient in these circumstances can
keep them upon his stomach; and even when they are not rejected
by vomit, they very seldom have force sufficient to answer the
end proposed. The more stimulating ones are certainly better
calculated to excite the peristaltic motion of the intestines, (the
one thing to be aimed at,) and thereby free the confined piece; but
on the other hand, if they do not succeed, they add to the fulness
and tension of the belly, as well as to the heat and thirst.
I would by no means be understood to mean that I am abso-
lutely against the use of cathartic medicines; I only mean to
signify, that I have no great dependence on them, and that I think
™ In a very pompous modem book may be seen an operose, expensive pro-
cess, for makincy an ointment of a solution of gold, pearl, &c. to be used for
assisting the reduction of strangulated intestines, and which, when pro-
perly made, may possibly be as useful as pomatum, ointment of elder, or any
other greasy application.
" The ingenious and learned Dr. Monro of Edinburgh, says, that he has
more than once reduced a rupture of this kind by a smart dose of jallap and
mercurius dulcis, when other methods have failed. The same gentleman says,
he has seen the external application of cold claret^ or snow, instead of a warm
poultice, used with good success.
VOL. I. tt IJ
33B A TREATISE ON RUPTURES.
persisting in the ineffectual use of them often adds unnecessarily
to the suffering of the patient.
But though I cannot say that I have seen frequent benefit from
the exhibition of cartharlics by the mouth, yet I have often ex-
perienced the good arising from acrid, stimulating clysters, and-
suppositories frequently repeated; particularly from the smoke of
tobacco" and from a composition of salt, honey, and aloes, boiled
to the proper consistence of a suppository. By these I have seen
very alarming ruptures returned, when they have been thought
capable of being relieved by nothing but the chirurgical opera-
tion.
There is another method of endeavouring to obtain relief in this
case, which has been proposed by few, and I hope practised by
ffewer (though I have seen two patients, upon whom n had been
tried, and who were both destroyed by it): it is the making several
punctures with a round needle through the tumid scrotum into the
gut, in order (as it is said) to let out the air which is supposed to
distend the latter, and prevent its return. If this practice was
worth a serious refutation, many arguments, drawn from the
nature both of the parts and of the disease, might be produced
against it: but it is really too absurd to waste either my own or the
reader's time about it.
There is no circumstance attending ruptures with stricture, in
which more variety is found, than in the time which they will
safely admit to be spent in their reduction: some have been suc-
cessfully replaced at the end of eight or ten days, others have
proved fatal in one. This difference may proceed from difference
of constitution and habit, or from some particular circumstance in
the disease itself; but let the cause of it be what it may, as it never
can be absolutely foreseen, it should never be trusted; the sooner
a rupture is reduced, the sooner the patient is out of danger from
the stricture, and the sooner will he be rid of those symptoms,
which it has already occasioned.
Recent hernias are in general more liable to stricture than old
• I cannot help tliinking that the present machine, which is used for the
tobacco clyster, might be considerably improved, that is, might be made to
throw in the fume in much greater quantity, and with more cert;iinfy. A
pump is now made for this purpose, which 1 have used very successfully.
A TREATISE ON RUPTURES. 339
ones; for reasons which are obvious from what has already been
said: but when old ones get into the same circumstances, the
symptoms are much the same; though 1 think in general they are
not altogeiher so pressing, and the latter generally admit of more
time to attempt reduction in. The smaller the portion of intestine
which is engaged, the greater the pain is, and the more hastily
do the symptoms advance. I have seen a bubonocele in a young
woman prove fatal in less than a day, which had never been down
before, and in which the portion of intestine was so small, as
hardly to engage its whole canal.
Omental ruptures in general are not subject to bad symptoms
arising from stricture; though they will sometimes be painful and
troublesome, from the connexion of the caul with the viscera, as I
have often seen. As this is an accident which they are all liable
to, they should never be suffered to remain down, if they are
reducible; and that not only on this account, but also because they
render the patient always liable to the descent of a piece of gut.
In general they are more easy of reduction than the intestinal,
and being not painful will admit of more free handling, as well
as more time to be spent in the attempt.?
I have already mentioned the reasons why an omental rupture
is sometimes incapable of being reduced, viz. adhesion to the sides
of the hernial sac, or such an alteration in the form of it, as makes
it impossible for it to passs through the abdominal aperture.
When this is truly the case, as is most reasonable to suppose
when it resists all proper attempts, there is no remedy but to sus-
pend the weight of it in a bag-iruss, and thereby render it as little
troublesome as possible. This is indeed all that can be done
when the rupture is absolutely irreducible; but in books will be
found directions to leave an old omental hernia down, and sus-
pend it in a bag, even though it should be reducible, rather than
return it into the belly, lest it should lie there in a lump, and
make the patient uneasy. This is one of those maxims which
writers receive from each other, and deliver down to posterity,
p WiUers of good credit have given accounts of the worst symptoms from
a mere epiplocele; in Dionis may be seen a case of this kind, in Gai'engeot,
and others.
340 A TREATrSE ON RUPTURES.
without inquiring into their propriety. It may in some few par-
ticular cases be right to do so, but cannot be admitted as a general
rule: surely it must always be worth while to try how it will be
when it is up, rather than be content with a method, which is
hardly palliative, and which always may be productive of new
evil.
When the parts are fairly reduced, the next consideration is,
how to keep them from falling down again: this can only be done
by a bandage, the pad of which must make a constant pressure
against the opening in the abdominal tendon, and thereby not
only keep the gut or caul from pushing out, but make the sides
of the hernial sac approach each other as near as possible.
In the making and adjusting this kind of bandage, some in-
genuity is necessary: if it be not so made, and so put on, as to do
good, it will do harm: if it does not keep the intestine up, the
patient is much more liable to mischief with it than without it;
and it has often, by pressing on the rupture while down, proved
very pernicious, in cases where there has been no degree of stric-
ture from the tendon. It therefore behoves every surgeon to see
that the truss which he orders is well made and properly applied,
lest all his pains should be baffled by the bad make, or injudicious
application of this piece of machinery.
If the symptoms of pain, inflammation, &c. ran high before the
parts were reduced, they will not always cease immediately after;
and as the symptoms which remain after the gut is returned, dq
in all probability proceed from its having been inflamed by the
stricture, such remedies as are proper in that case ought to be
made use of; the body should be kept open, and the diet and
regimen should be low and sparing, while the least degree of ten-
sion or pain remain; in short, till all complaint is absolutely re-
moved from the abdomen, and the intestines do tlieir office freely,
and without trouble.
4 TREATISE ON RUPTURES.
SECT. V.
341
I AM now come to the fourth division, under which I compre-
hended all those ruptures, which are in such a state as to be irre-
ducible by the mere hand, and in which a chirUrgical operation is
necessary Tor the preservation of the life of the patient.
Impracticability of reduction may be owing to many causes,
most of which have already been recited; such are, alteration of
the form of the parls contained in the hernial sac, largeness of
their quantity, adhesions either to the sac, or to each other, or
both, and a stricture made on the intestine, by the borders of the
aperture in the abdominal tendon: these are each of them causes
why ruptures are sometimes incapable of being returned back
into the belly, and will require our consideration in their proper
places; but in this it is my intention to speak only of the last, it
being that which calls most immediately for relief, which most
frequently requires the surgeon's knife.
Whether the primary and original cause of the mischief arising
from this stricture, be in the contained, or in the containing parts
of a rupture, I will not now stay to inquire; nor whether the stric-
ture made by the tendon be a cause, or an effect; but shall con-
sider the intestine as so engaged in it, as to be rendered incapa-
ble of being returned into the cavity of the belly, (by the hand
only,) and suffering in such manner, by being so bound, as to
produce a series of bad symptoms, and at last (if not relieved)
death.
This stricture, which according to its different degrees renders
the reduction of an intestinal hernia either difficult or impossible,
is according to such degrees productive of what are called the
symptoms of a strangulated rupture, and which are more or less
pressing, as they more or less interest the life of the patient.
The earliest of these symptoms were related in the former sec-
tion, as attendant on those ruptures which were reducible, though
with difficulty, viz. tumor in the groin or scrotum, attended with
pain, not only in the part, but all over the belly, and creating a
fickness and inclination to vomit, suppression of stools, and some
A TREATISE ON RUPTURES.
degree of fever: these are the first symptoms, and if they are not
appeased by the return of the intestine, that is, if the attempts
made for this purpose do not succeed, they are soon exasperated;
the sickness becomes more troublesome, the vomiting more fre-
quent, the pain more intense, the tension of the belly greater, the
fever higher, and a general restlessness comes on, which is very
terrible to bear. When this is the state of the patient, no time is
to be lost: a very little delay is now of the utmost consequence;
and if the single remedy which the disease is now capable of be
not administered immediately, it will generally baffle every other
atlempt. This remedy is the operation, whereby the parts engag-
ed in the stricture may be set free. If this be not now performed,
the vomiting is soon exchanged for a convulsive hiccough, and a
frequent gulping up of bilious matter; the tension of the belly, the
restlessness, and fever, having been considerably increased for a
few hours, the patient suddenly becomes perfectly easy, the belly
subsides, the pulse from having been hard, full, and frequent, be-
comes low, languid, and generally interrupted; and the skin, espe-
cially that of the limbs, cold and moist; the eyes have now a
languor and a glassiness, and a lack-lustre not easy to be de-
scribed; the tumor of the part disappears and the skin covering it
sometimes changes its natural colour for a livid hue; but whether
it keeps or loses its colour, it has an emphysematous feel, a cre-
pitus to the touch, which will easily be conceived by all who
have attended to it, but an idea of it is not so easy to be conveyed
by words: this crepitus is the too sure indicator of gangrenous mis-
chief within. In this state, the gut either goes up spontaneously,
or is returned with the smallest degree of pressure; a discharge is
made by stool, and the patient is generally much pleased at the
ease he finds: but this pleasure is of short duration, for the hic-
cough and the cold sweats continuing and increasing, with the ad-
dition of spasmodic rigors and subsultus tendinum, the tragedy
soon finishes.
These are the symptoms of an incarcerated hernia, this their
general progress, and their too frequent event. The first class of
them imply some degree of hazard, but are often capable of being
relieved without the use of the knife; the latter frequently require
A TREATISE ON RUPTURES. 343
it, and very often prove fatal by the neglect, or too late applica-
tion of it.
Perhaps there is not in the practice of surgery a point which
requires more judgment, firmness, or delicacy, than to determine
the precise time, beyond which this operation should not be de-
ferred, and for a surgeon to conduct himself so as to induce a pa-
tient to submit to it early enough for his preservation. The lime
in which 'a piece of gut will become gangrenous from stricture, or
get into a state approaching to that of a gangrene, is extremely
uncertain, and depends upon circumstances which no man can
foresee. There have been several instances of ruptures, attended
by pressing symptoms of stricture, which have been safely re-
turned by the hand oioly, at the end of several days; or the opera-
tion having been performed at the same distance of time, the
parts have been found sound or unhurt: on the other hand, there
are many instances producible, of the intestine having been with
great difficulty replaced, or of its returning, sua sponte^ from being
mortified, or (the operation having been submitted lo) of its hav-
ing been found in such state by the operator, at the end of not
many hours.
I have myself seen a small portion of the intestine become per-
fectly gangrenous, in one day and night from its first expulsion.
The directions which are given to us by writers, are not to be
trusted without much circumspection; the signs or marks which
they in general regard as proofs of the proper time for operating,
are most frequent proofs that the time is just elapsed, and that,
instead of waiting for the arrival of such symptoms, we should
have prevented them. On the other hand, to propose an opera-
lion of so much consequence, before it shall be thought absolutely
necessary, may admit of such misconstruction, as no man would
wish to have put upon his conduct. Indeed, I do not know any
situation, in which a judicious and prudent man can be placed, in
which it will behove him to be more wary and circumspect, more
delicate, or more steady.
The two principal circumstances which have most contributed
to the infreqnency of performing this operation, are, a dread of
great hazard from the operation itself, considered abstractedly,
and a fear of bringing a disgrace upon it, by having performed it
344 A TREATISE ON RUPTURES.
too late, ne occidisse^ nisi servasset, videretur.'^ The first of these
is vastly greater than it ought to be, and is most frequently the
cause of the latter; so that if the one can justly be lessened, the
other will not be so likely to happen.
That the operation considered simply is not void of hazard;
every man who knows any thing of the nature of wounds in mem-
branous and tendinous parts, must acknowledge: they are cer-
tainly subject to fever and inflammation, are difficult and slow of
digestion, and in some particular habits are apt to become gan-
grenous; but that they are necessarily, or even most frequently
hazardous, daily and manifold experience contradicts.
One evil is very frequently the parent of others. By being
afraid of incurring that degree of hazard which is thought to at-
tend the operation merely, the generality of people neither attend
to, nor embrace the most proper time for the safe performance of
it; or that in which its danger must be necessarily least, be-
cause least combined with that which may arise from the state of
the parts within; a state even at first not absolutely safe, but
which all delay beyond a certain time must hourly increase the
hazard of.
If I might presume to give my opinion on this subject, I should
say, that the operation ought always to be performed as soon as pos-
sible after it appears that all rational attempts, by large and free
bleeding, the warm bath, clysters, &c. are found to be ineffectual,
or that the symptoms rather increase than decrease, while such
means are made use of, and that the" handling necessary for
9 Celsus.
I Perhaps I maybe thought somewhat singulai' ; but from what I havf
seen, I am much inclined to believe, that when the parts are very painful to
the touch, and the scrotum large, and much upon the stress, more harm is
generally done by the manual attempts for reduction, than good. In this state,
the great distention of the intestine renders it very incompressible, and very
little likely to be returned tlirough the tendinous aperture by mere force,
(for such it is, in whatever degree it is used,) and either a brisk irritatin,^
purge, or a very stimulating clyster, (particularly the tobacco-smoke,) are
more likely, by exciting the peristaltic motion, to disentangle it, than even
the most judicious method of handling it. And in cases where such remedies
have been previously used, I verily believe the sudden reduction of the piece
of gut is often more owing to their effect than to that of the hand. Uiit I
A TREATISE ON RUPTURES. 345
reduction becomes more and more painful; for if it be delayed until
the inflammation has attained a certain height, though the parts
upon being laid open are not found quite gangrenous, that is no
proof that the want of success must be set to the account of the
operation merely. That state of inflammation, either of the in-
testine or of the hernial sac, which is just not gangrenous, is no
state of safety, nor are we sure that removing the stricture will at
this time appease the symptoms, or abate the hazard: far from it:
such an alteration may have already been made in the intestine,
that a mortification will ensue, though it be set free and returned
into the belly. A ligature need not be continued round any part
of a living animal, until it becomes quite gangrenous, in order to
produce its destruction. There is a certain point of time, in
which the circulation is so prevented, that the same event will
follow, though the ligature be then removed. It is indeed a nice
and no very easy matter to find this precise time: but this diffi-
culty and uncertainty are the strongest reasons for anticipating
rather than waiting for it; for when in the present case such time
arrives, or is nearly arrived, the risk of the operation becomes
complicated with that arising from the diseased state of the parts
within; and the chance of success is thereby much lessened.
A mortification of the intestine is not absolutely, necessarily,
and always fatal: but the instances of those patients who have
escaped with life in these circumstances are so very few, that it
may fairly be reckoned among the deadly diseases. If the mor-
tified gut returns back into the belly, upon the gangrene taking
possession of the part which was bound, it will most probably
prove fatal; and though there have undoubtedly been instances
of people who have survived the operation, though it has been de-
layed till the parts have been in such condition, yet they are so
very rare, that they are hardly sufficient to found a reasonable
expectation upon; and of the very few who have thus escaped,
must desire that this may be rightly understood, and not mistaken for a dis-
suasive against manual attempts for reduction ; I only mean, that there is
such a state of an incarcerated intestine, (which state I have just described,)
in which, from its size, inflammation, distention, &c. compression by the
hand is very little likely to procure its return, and very likely, if it does not
do so, to do considerable mischief,
VOL. I. , X X
346 A TREATISE ON RUPTURES.
the majority have been obliged to hold life upon terms which
have oeen very fatiguing and disagreeable.
When the operation shall be thought necessary, the manner of
performing it is as follows: —
The pubes and groin having been clean shaved, the patient
must be laid on his back, on a table of convenient height, with
his legs hanging easily over the end of it: then wiJh a straight dis-
secting knife an incision must be made through the skin and
membrana adiposa, beginning just above the place where the in-
testine passes out from the belly, and continuing it quite down to
the lower part of the scrotum. Upon dividing the adipose mem-
brane, there generally appear a few small, distinct, tendinous kind
~of bands, which lie close upon the hernial sac, which must be di-
vided also, as well as the sac: the same knife with which the in-
cision through the skin was made will execute this, which should
be done wi(h a steady hand and great caution, it being of very
different degrees of thickness in diiferent cases: in the bubono-
cele, or that which is confined to the groin, the sac is most fre-
quently thin, consequently more easily divided, and requires
greater attention in the operator: in the oscheocele, or scrotal
hernia, if it be recent, the sac is usually thin also; if ancient, it is
sometimes of considerable thickness; but whatever be the state of
it, if the o{)eralor has any doubt, let him, as soon as he had made
a small puncture in what appears to him to be the hernial sac, en-
deavour to introduce a probe into it: this will give him the neces-
sary satisfaction; for if he has not pierced the sac, the probe will
be stopped by the cells of the common membrane; and, if he has,
it will pass in without any obstruction. The place to make the
incision in the hernial sac is about an inch and a half below the
stricture, a::d 'he opvning need not be larger than just to admit
the < n of \be operator's forefinger, which, considering the grtat
diiot b^iiy of ihtse membranes, will be a very small one. The
fore-finger introduced inio this aperture is the best of all directors,
and upon that a narrow-biaded, curved knife, wiih a bold probe
poiai, will be the only instrument necessary to finish ihe opera-
tion. Wif.li this knife on the finger, (the point of the foim r be-
ing alwajs shori of the exiremiiy of the latter,) the sac must be
A TREATISE ON RUPTURES. 347
divided quite up to the opening in tiie tendon, and down to the
hotloui of the scrotum.
Upon the first division of the sac, a fluid generally rushes out,
which fluid is dilTert^nt in quantity, colour, and consistence, ac-
cording to the date, size, and some other circumstances attending
the rupture.
This fluid has sometimes been mentioned as a defence against
an accideat from the knife, in the first division of the hernial sac,
as if it kept the intesane at such a distance, as diereby to lessen
the hazard of iSs being wounded; but this is a very fallacious cir-
cumstance, and never to be trusted: the security of this operation
depends entirely on a competent kno.wledge of the parts, a steady
hand, and an attentive eye.
Different operators, especially among the French, have proposed
a number of different instruments for the safe performance of this
incision; the bistouri cachee, the bistouri herniare^ the wii|ged di-
rector, the blunt scissors, &c. &c. &c. all which are calculated
for the defence and preservation of the intestine, in the division
of the sac and tendon; but whoever will make use of the two
knives just mentioned will find that he will never stand in need
of any other instrument, and that he 'will with them be able to
perform the operation with more ease to himself, with less hazard
to his patient, and with more' apparent dexterity, than with any
other whatever.
* They who are not accustomed to perform operations of such conse-
quence as this is, are apt, from timidity, to be too spuriug in making their
external incision, by whicii means they add considerably to their own em-
barrassment, and to the futigue of the patient. A free division of ihe hernial
sac and scrotum, downwards, gives room for the more easy admission of tlie
finger into the stricture, in order to divide it, and affords an opportunity of
handhng the intestine or omentum more gently, as well as more properly,
in order to return them into the belly, both which necessary parts of the
operation are much impeded by a small incision.
As therefore no possible advantage can arise from a small wound, but on
the contrary it may be attended with great inconvenience both to the patient
and surgeon, I would take the liberty of advising, when such an opening is
made in the hernial sac as will admit the operator's fore-finger, and upon it
his knife, that he immediately divitle the sac and scrotum down to the bot-
tom. It is true, that upon such division the quantity of intestine will seem to
be increased, and an ignorant by-stander may be alarmed at this fallacious
348 A TREATISE ON RUPTURES.
The sac being laid open, the intestine generally pushes out Im-
mediately, (unless it is confined, by being enveloped in the omen-
tum,) and appears to be much more in quantity than it seemed to
be, while it was confined within the scrotum.
This is the time to try whether, by gently drawing out a little
more of the gut, its bulk cannot be so reduced as to enable the
surgeon to return it back into the belly, without dividing the ten-
don. In the case of the protrusion of a very small piece of intes-
tine it has been found practicable, the difficulty of returning a
large portion arising principally from the quantity of mesentery
engaged in the stricture; and, indeed, though it may now and
then happen that a small piece of gut may be returnable without
a division of the tendon, yet, if it cannot be very easily accom-
plished, it had better not be attempted, since in the state in which
this part must necessarily be to require the operation thus far,
any degree of force used to it will, most probably, be more pre-
judicial and hazardous than the rest of it, if performed properly
with a knife.
An attention to the natural structure, figure, and direction of the
parts, will give us the best information how to make the divisiou
of the stricture to the best purpose, and with the least hazard.
The tendon of the obliquus descendens muscle runs in aa
oblique direction from above downward, and the natural opening
which is always found in it, and through which the hernia passes,
is made by a kind of separation of the fibres from each oriier.
The direction of this opening is the same as that of the undon,
that is, obliquely downward, from the os ilion to the os pubis: the
knife therefore should be so managed, as rather to continue this
separation, than to make any transverse section; its edge should be
applied to the superior and posterior part of the oval, and carried
upward, and obliquely backward, until a sufficient opening is
made to serve the purpose. By this means the fibres of the ten-
appearance, which is produced merely by the confined compressed gut be-
ing set free, and not by the addition of any more. The advantage wliich will
arise to the operator, and consequently to the patient, from such division is
real and great : it will enable tlie former to finish his work with freedom, aniA
spare the latter a great deal of pain
A TREATISE ON RUPTURES. 349
don will be rather separated from each other than cut, and in all
probability the risk arising from the incision will be lessened.
It is generally advised lo make the division of the stricture free
and large, as well to permit the easy return of ibe parts, as to pre-
vent the inconvenience which it is supposed will be more likely to
attend a small wound in a tendinous body than a large one: the
first intention, the easy return of the intestine, should certainly be
fulfilled, and therefore the incision ought always to be large enough
for that purpose, and to afford an opportunity of passing the end of
the finger round on the inside in case of any adhesion; but as too
large an opening may be attended with very ill consequence, it
ought also to be guarded against. In the majority of cases, a small
incision will be found sufficient for the purpose of reduction; and
where the parts are free from adhesion, and the safe return of
them is the only object of attention, a small division made in the
manner already directed is not liable to any more pain and trouble
than a large one, and may therefore be safely trusted.
Among the authors who write from each other and not from
practice, are to be found accounts of cases, in which the tendon
only has been divided, and not the hernial sac, which latter has
been returned through the enlarged opening, with its contents
enclosed; and the same writers are very particular in their direc-
tions how to accomplish this operation. If it was practicable,
(which the universal adhesion of the sac with the cellular mem-
brane of the spermatic chord renders absolutely not so,) there
would be still several material objections to the doing it; which
objections, as the thing is not capable of being executed, it is
needless to mention.
Though I am perfectly satisfied that the case of a strangulated
hernia is most frequently as I have represented it, viz. that the
disorder in the intestine is originally produced by the stricture
made on it by the borders of the tendinous opening of the abdo-
minal muscle, and that the gut is in general perfectly sound, and
free from disease, before it becomes engaged in such stricture, yet
I think it right to acquaint the uninformed reader, that it has been
and still is the opinion of some very ingenious men, that the dis-
ease is originally in the gut, and that the stricture is an accident
350 A TREATISE ON RUPTURES.
arising from the inflammation and distenlion of it; or, in other
words, that the intestine is first inflamed, and, by means of the
alteration produced by such inflammation, becomes too large for
the tendinous aperture, which therefore makes a siriciure on it,
and which, ihey think, is tlie reason why the chirurgicai operation
is often unsuccessful.
For my own part, I cannot think that either the fact or the
inference is in general true.
An inflammation most certainly may, and frequently does,
attack any part of the imestinal canal; and consequently shat part
of it which happens to be included within a hernial sac may acci-
dentally be so aflecled. When this is the case, the swelling and
distention which naturally and necessarily attend an inflammation
of the gut, will render it less capable, or perhaps quite incapable,
of repassing the opening in the abdominal tendon, which tendon
mav therefore make such stricture on the part so diseased, as
greatly to heighten the first symptoms, and bring on si ill worse;
and when this happens, the operation will also be less likely to be
successful, it being calculated for the relief of only such symptoms
as arise from a piece of intestine (in other respec.s sound and free
from disease) being so bound by the said tendon, as to have its
peristaltic motion, and the circulation of the blood through it, im-
peded or stopped: whereas, the other complaint, consisting pri-
marily and originally in an inflammation of the gut itself, the
mere removal of it from stricture is not, nor can be, equal to
the cure of the disease. That the case is a possible one I make
no doubt, having once or twice seen it in old ruptures; but it is a
very rare one, and by no means to be admitted either as a proof
that the mischief done to the intestine, in the generality of strangu-
lated ruptures, does not most frequently proceed from the stric-
ture made by the tendon, or a dissuasive from performing an
operation, whenever it would otherwise be thought necessary.
It is not however a mere speculative point; it is really a mat-
ter of consequence, and ought to be attended to by all those who
have it in their power to make frequent observations on such sub-
jects; for on the truth or falsehood of this doctrine depend a few
very material points in practice, some of which ought so to in-
A TREATISE ON RUPTURES. 351
fluence a surgeon's conduct as to make it considerably different in
one case from what it should be in the other.
Very bad symptoms, such as pain, tension of the belly, sickness,
vomiting, hiccough, fever, and suppression of stools, are often pro-
duced in a very short space of time by the descent of a piece of
gut, upon some exertion of strength in persons who were imme-
diately before such accident at perfect ease, and free from all
complaints relative to the belly. If the disease be not discovered,
or if our attempts to reduce the intestine are not successful, these
symptoms are heightened, and the patient often dies of a mortifi-
cation: if we do succeed in the timely reduction, all these terrible
symptoms often cease instantaneously, and the patient feels neither
pain nor inconvenience of any kind from that moment. Would
this most probably and most frequently happen, if the disease was
generally in the intestine, and the stricture of the tendon merely
accidental?
In that kind of disease of the intestinal tube, which is said to
be produced by inflammation, and thought to be attended with
spasmodic stricture, or contraction of its muscular fibres, there is
such an alteration made in its peristaltic molion, and such impe-
diment in the execution of its principal offices, that what is taken
into the stomach is rejected by vomit, and faeces are not protruded
through the colon and rectuni, the belly is tight and painful, the
skin hot, the pulse quick and hard, and the patient feels a rest-
lessness and anxiety which are very disagreeable: this is one of
those cases which require immediate assistance, and will admit of
no delay: the progress of the symptoms from bad to worse is gene-
rally very rapid: and if the disease be not soon subdued, the
patient dies. Free and repeated evacuation by phlebotomy and
lenient purges, the use of a semicupium, a warm bath, clysters,
and sometimes brisk cathartics, joined with opium, are the reme-
dies generally prescribed, and if made use of in time are often suc-
cessful; but if n€glec!ed, the case most frequently ends ill.
It is very true that the same sympJoms occur in a strangulated
hernia; but if ihat hernia be reducible, they generally cease upon
such reduction, nor <ioes the pa; lent want any other assistance
than what is necessary to prevent a new descent of the gut. In
this respect therefore the two diseases differ very materially: in the
852 A TREATISE ON RUPTURES.
latter, nature stands in need of no further assistance from art, but
as soon as the ni.innal operation is performed, returns to the execu-
tion of her natural functions; in the former, she is found so very
insufficient toward assisting herself, that it seems to be one of the
few cases, in which medical assistance can hardly ever be dis-
pensed with.
Noiv, if (he bad symptoms attending an irreduced rupture were
primarily owing io an inflammation of the intestine within it, and
that the tendinous aperture made a stricture on it, only in conse-
quence of ihe distention of the gut — allowing this stricture to
aggravate the complaint considerably — yet the division of it, or
the reduction of the intestine, can never be supposed to do more
than alleviate or remove such aggravation; the original inflamma-
tion of the gut tuust stil! remain, nor can it be lessened by the in-
testine having been girt tight by the tendon; and yet, as I have
just now observed, we very rarely (at least in ruptures that are not
of ancient date) meet with any trouble or complaint after reduc-
tion 'is timely and completely made, and the intestine returned
into the belly in a sound state; the vomiting most frequently ceases
immediately, or in a very short space of time; a discharge is made
by stool, the tension of the belly goes off, and though the patient
is not always instantaneously well, in cases where the symptoms
have been very threatening, yet all such complaints, as proceeded
from an obstruction to the execution of the proper oflices of the
intestinal canal, generally disappear immediately.
From the nature and progress of the symptoms in a miserere,
(as it is called,) from the extreme pain of the first attack, from the
perfect ease a little while before death, and from the mortified
appearance of the intestines after such event, I think it is most
probable, that, if we could have an opportunity of seeing the in-
testine during the first part of this complaint, we should find all
the appearances of inflammation: whereas, in many of those upon
whom the operation for the bubonocele is successfully and timely
performed, this is not the case; the intestine seldom bears marks
of high inflammation, unless the operation has been long delayed,
nor do the symptoms of such complaint usually attend afterward;
the mortified part often does not exceed an inch, or an inch and a
half in length, and is almost always confined to that part of the gut
A TREATISE ON RUPTURES, 353
which is on the outside of the tendinous opening, all within the
belly being sound and fair. To which may be added this circum-
stance, that when the parts contained in a hernial sac become
mortified by the delay of the operation, the sac itself, (which has
no immediate connexion with the intestine or its vessels,) the cel-
lular membrane covering it, nay the skin, is often found in the
same state.
These are my principal reasons for believing that the mere
stricture made by the tendon is, in the generality of incarcerated
ruptures, not only a sufficient, but the primary, and indeed the
sole cause of all the symptoms, and all the mischief; and there-
fore I must also be of opinion, that whoever neglects to perform,
or at least to propose the operation, when he finds reduction iiTt~
practicable, and the symptoms pressing, does in some measure
contribute to the destruction of his patient.'
On the other hand, I am convinced, by some instances which I
have met with, (and which one time or other I hope to be able to
present to the public in a collection with many others,) that the
©pinion has some foundation in truth, and that persons labouring
under old ruptures, which have been long in the scrotum without
giving any trouble, in which the quantity of intestine is often very
large, the tendinous aperture much dilated, and the hernial sac
thick and firm, are those to whom this misfortune has happened,
and who indeed, if their case be duly considered, will be found
most liable to it; there being no reason in nature why that part of
the intestine which is contained in such a hernia, should not be
« Indeed, though we should Suppose the case to be as those gentkmen
have represented it, viz. that the complaint begins in the intestine, and that
the stricture made by the tendon is not a primary cause, but an effect of the
disease, I do not see how we can avoid proposing the opei-ation ; for whether
the increased size of the gut be owing to the inflammation, which renders it
too large to pass the abdominal opening, or whether it be the mere effect of
stricture made by the tendon, in either case it will bind equally, and the
event must be exactly the same, as far at least as the stricture has to do
with it : for when the intestine is inflamed, whether such inflammation pre-
ceded or succeeded the confinement of it by the tendinous opening, the
symptoms can never be appeased, but by the release "of tlie gut from itr
confinement.
VOL.^ I. - TV
354 A TRKATlSli 0I'« RUPTURES.
subject lo every complaint, or disease, to which every other part
of that canal is liable; and this opinion I am more confirmed in, by
having met vvifii more tlian one subject with such old ruptures.,
who have had all the symptoms of a strangulation; and in v^'hom,
I am sure, there was no stricture made by the tendon, though the
gut remained in the scrotum.
Although I have through the course of this section repeatedly
recommended the early performance of the operation, yet I must
desire not to be niisundefslood, as if I meant to advise it before
proper attempts iiad been made for reduction, or the symptoms
become alarming; much less that I would propose it as a means
to obtain a radical cure in those ruptures which are returnable by
the hand merely; a thing boasted of, and practised by pretenders,
but not to be thought of by any man who has either judgment,
humanity, or honesty.
The only intent of it should be to preserve life, by rescuing the
patient from the hazard of mortification, likely to ensue from the
stricture; and though I have pressed it with such view, and in such
circumstances, and think it ought always to be done, yet I should
be rery sorry to have it thought that I encouraged the performance
of it wantonly, or unnecessarily, which must be the case, when-
ever it is done with any other intention.
Considered as a means to obtain a perfect or radical cure, or to
prevent the necessity of wearing a truss, every man at all conver-
sant with these things knows, that it most frequently fails of pro-
curing that end; and that most of those people who have been
obliged to submit to it for the preservation of their lives, have also
been obliged to wear a bandage ever afterwards, to prevent the
intestine from slipping down behind the cicatrix into the groin.
In short, though the danger from the operation, when perform-
ed in time, is in my opinion never to be mentioned with that which
must arise from the stricture, if neglected, yet such operation
never ought to be attempted but with a view to prevent the im-
pending ill effects of such stricture, and will not ever (I dare be-
lieve) be put in practice with any other intention, by any fair or
judicious practitioner, by any man who has the least regard for
A TREATISE ON RUPTURES. 35£i
his own character, bis feilovv-creaturc's sensations, or for any thing
but money."
The sac and stricture being laid open and divided, the contained
parts come into view, and, according to the different circum-
stances of the rupture and of the patient, will be found in differ
ent states, and require different treatment.
These states are reducible to three general heads, that is, the
contained parts will be found, either in a sound, healthy, loose,
unconnected state, and fit for immediate reduction; or in a sound
state, but, from some particular circumstances, incapable of being
immediately replaced; or in an unsound diseased state, and re-
quiring to be treated accordingly.
If the rupture consists of a piece of intestine only, and that
oeither mortified nor adherent, the sooner it is returned the better,
and the more gently it is handled for reduction the better also.
If the intestine be accompanied with a portion of omentum, the
latter (if in a proper state) should be returned first.
In returning the intestine, care should be taken to endeavour to
put in that part first which came out last, otherwise the gut will
be doubled on itself, and the difficulty and trouble be thereby
much increased; and in making the reduction, the fingers should
be applied to that part of the intestine which is connected with
the mesentery, rather than its convex part, as it will both serve
the purpose better, and be less likely to do mischief.
While the reduction is making, the leg and thigh on the rup-
tured side should be kept elevated, as such position of the limb
will much facilitate the return of the parts.
Long confinement in the scrotum will, in some people, produce
slight adhesions, by slender filaments, which are generally very
easily separated by the finger, or divided by a knife, or scissors,
'° Perhaps it may appear extraordinary, but this necessarily severe opera-
tion has, by some of our modern quacks, been recommended, and even
practised, for the cure of omental hernias : more tlvan one person has lost
his life, that is, has been murdered in the attempt : but that seems to be
a circumstance of small importance in the minds of these operators, nor
does it at all prevent the credulous part of mankind from trusting them ;
though one would imagine that much stronger proofs, either of the judg
ment, humanity, or honesty of Puch practitioners, were not requisite.
356 A TRKATISE ON RUPTURES-
wbether the adhesions be of the parts of the intestine inter se, or
to the hernial sac. If the adhesion be of the former kind, anti
such as proves very difficult to separate, it will be better to return
the gut into the belly as it is, than to run the risk of producing an
inflammation by using force: if it be of the latter, that is, if the
connexion be with the sac, there can be no hazard in wounding
that, and therefore it may be made free with.
It has been said by some writers, that if the piece of omentum
be so very adherent that the surgeon does hot choose to separate it,
that it may very safely be left, that it will first suppurate, and then
shrink, and very little retard the healing of the sore. What expe-
rience the gentlemen who talk in this manner may have had of this
kind of case, I know not; but I never yet have seen any, in which
it could possibly be thought necessary to leave the patient in such
circumstances, or in which an attachment of the omentum was in-
capable of being set free, either by dissecting its adhesions, or re-
trenching a part of it.
The prolapsed part being replaced, the next object of consider-
ation is the hernial sac: this, if large, thick, and hard, will prove
slow and difficult of digestion, render the edges of the sore tumid
and painful, and often retard a cure considerably, by producing
troublesome abscesses in the scrotum.
A considerable part of it may very safely and properly be re-
moved: no part of it is of any consequence except the posterior, or
that with which the spermatic vessels are connected: all the rest
being loose, by means of the cellular membrane, is therefore very
easily separable, and had therefore better be removed than left."
" The removal of part of the sac might have been right when the practice
was to fill the cavity witli dressings, which induced a necessity for the mem.
branous sac to slough, but was very contrary to Mr. Pott's pi-actice in the
latter part of his life ; and, if he had lived to produce a new edition of this
treatise, as he had projected, I have no doubt but that this passage would
have been altered. The method which we have long used, and which Mr.
Pott himself practised, is this : when the contents of the sac are returned
into the abdomen, the sides of the scrotum are brouglit together, by which
means the parts of the divided sac are also brought into contact, a large armed
needle is then passed through the upper part of the scrotum near to the ab-
dominal ring, and made to dip down, so as to pass through the sides of the
sac, but by no means so deep as to run any risk of including, or even injur -
A TREATISE ON RUPTURES- 357
It has been proposed by theoretic writers to pass n ligature
round the upper part of llie neck of the sac, in order, as it is said,
to procure the union of its sides, and thereby more certainly to pre-
vent the future descent of any thing from the betly; but to this
there are many objections: the principal of which are, (hat if the
ligature was not made strict, it could serve no purpose; and if it
was, it would be very likely to injure the spermatic chord, if in-
cluded in it. By preventing part of the discharge, it might also
occasion very troublesome symptoms, and, upon the whole, ia by
no raeans advisable.
It has also been supposed, that the intestin.e may be found so
inherent as not to admit of being set free; and in this case, it has
been advised to remove the stricture, by* dividing the sac and the
tendon, and then to leave the parts loose. This is mentioned by
many writers of eminence, and therefore I have taken notice of it,
though it is a kind of case which, I must own, I have never seen,
nor do I suppose that I ever shall. I have seen the intestines very
firmly adherent to each other, to the sac, to the omentum, and tp
the testicle; but, never in such a state of adhesion, as to be inca-
pable of being returned. The adhesion of the parts of the intes-
tine inter se are most frequently easily separated; but if they should
not, still these are no hinderance to the gut being returned; and if
the caul be so connected as to prove troublesome to detach, it may
with great safety be cut off; so that the connexion here meant must
be of the intestine with the hernial sac: of these two parts we are
interested only for the preservation of one, and may without ha-
zard make free with the other. The separation may indeed be
tedious, and sotiietimes difficult; but, let the difficulty or trouble 1?€
what they may, the separation must be accomplished, it being ab-
ing, in the smallest degree, the spermatic vessels, by which mode the objec-
tion in the paragraph which follows in the text, is done away; the ligature
is then to be tied moderately fast, which makes a powerful barrier against the
reprotrusion of the intestine. Two or three stitches, according to the size
of the incision, are then to be made through the sides of the divided scrotum-i
there is no necessity for these to pass through the sac, as the only intention
of them is to keep the parts together, so as to prevent the exposure of the
sac, by which means no digestion of it will take place, but the parts will
coalesce, and generally he%l by the first intention. E.
358 A treatisl; on ruptures.
surJ to think ol' h^Tviiig a piece of intestine loose, in the dividea
scrotum, which, from the removal of the stricture above, will be
liable to be increased in quantity, from every unguarded motion,
and subject to all the inconveniences which the influence of the
air must necessarily produce on such tender parts; not to mention
the great diflicuUy of managing the sore in this state, and the pain
and other bad symptoms which must arise from the daily uncover-
ing the intestine. Any trouble, therefore, which may attend the
separation, must be submitted to, rather than to follow this strange
advice, which, indeed, the writers who give, seem not to under-
stand; for, to leave the parts as they were found, and as they di-
rect, is impossible: they were found contained in a hernial sac,
and in the scrotum, defended from the air, and in some degree li-
mited as to quantity, both by the stricture above, and the sac be-
low; the necessary operation has removed that stricture, divided
the sac and scrotum, and set all loose and free; and, therefore, if
the intestine be not returned into the belly, and kept there, the
quantity which may fall out may be so large as to produce the
most fatal consequences, notwithstanding any attachments which
some part of the canal may have contracted.
SECT. Vi.
Hitherto the pat Is composing a rupture have been considered
*^s displaced, as inflamed, as having contracted unnatural connex-
ions and adhesions, but being still so unhurt in their texture as to
remain sound, within the laws of the circulation, fit to be return-
f'A into the belly, and affording a reasonable prospect of success
in the event.
But, on the other hand, if the inflammation ran very high, and
lias cither been neglected, or not given way to proper treatment,
and the operation has been too long deferred, the parts, though
loose, may berorne so diseasedj as to be unfit for immediate re-
«^uetion.
A TREATISE ON RUPTURES. 359
The disease here meant is gangrene, or morlificalion, produced
by the stoppage of the circulation of the blood through the part
which is on the outside of the stricture. The gangrenous or mor-
tified state of these parts may be of more or less extent, according
to the quantity contained in the sac; but be the extent of such dis-
ease what it may, the part so aifected ought never to be returned
loose into the belly, (more especially if it be intestine,) withont
some caution.
The omentum indeed may be made more free wlili. If this
be so altered as to be plainly unfit for immediate reduction, it may
be removed; that is, the altered part may be cut oif from the
sound.
This is certainly true; but it is a point of practice which ap-
pears to me to deserve somewhat more regard than is most com-
monly paid to it by writers. All that is generally said of it is,
that if the omentum be found in an unsound state, a ligature
should be made on it just above the altered part: what is below
such ligature should be cut off, and the ligature should be left
hanging out of the wound, that it may more easily be taken away,
when it is cast off This is the general doctrine, and indeed the
general practice; but which I cannot help thinking is delivered
down, and followed by us, somewhat inconsiderately.
When the omentum is in such state as to be fit for being re-
turned into the belly, such return ought never to be neglected or
omitted; the uses of the caul are great and obvious, and the want
of it must be productive of inconvenience to the patient; its
warmth, its greasiness, its lubricity, its extension over the surface
of the intestines, together with the constant motion of that canal,
prove its utility, and in some measure point out what the incon-
veniences must necessarily be, which follow the removal of it.
But it is sometimes found in such state, as to be unfit for reduc-
tion; and then we must embrace the lesser of the two evils, and
remove such part of it as we ought not to return. This is said
by every body, and is certainly true; but seems to me, as I have
just now observed, to require more consideration than is generally
spent upon it, as well with regard to the state requiring such
operation, as the manner of executing it. It is commonly said,
ihat if it be found in large quantity, considerably hrirfl(?ned. or if
360 A TREATISE ON RUPTURES.
it be altered in its texture, (that is, by gangrene or morlitication,)
that it ought to be retrenched. The two states said to require
this retrenchment are very materially different from each other:
the necessity of it in the latter is evident; but I cannot help say-
ing, that I think it is ordered in the former very unnecessarily;
and that the general method also of performing it in the latter
appears to me both injudicious and prejudicial. There may pos-
sibl}' now and then occur a case, in which such alteration may
have been made in the mere form and consistence of the pro-
lapsed piece, by induration, enlargement, &,c. that the removal of
a part of it may become necessary; but this, though it does happen
sometimes, is very unfit to be made a general rule of. The reason
given is, that it will lie uneasy in a hard lump within the pa-
tient's belly; which is not necessarily or generally true, as I have
several times experienced; having returned it when its form and
consistence have been much altered, without finding any future
inconvenience: so that such alteration merely is not a general rea-
son for cutting it off. On the other hand, I am ready to allow,
that it sometimes is, and that the piece of caul so altered had bet-
ter be removed, and that it may also be so connected, that it will
be more to the patient's advantage to have such connected part
taken away at once, than to go through the pain and fatigue which
the separation may require; in which case, my objection lies prin-
cipally against the prescribed method by ligature. Indeed, when
it is in a gangrenous state, a part of it must necessarily be re-
moved, as such state makes the return of it into the belly highly
improper. To accomplish this, we are ordered to make a liga-
ture on the sound part of the omentum, just above what is altered,
and then to cut it off immediately below such ligature: and the rea-
son given for doing it in this manner is, that all the altered part
may be removed without any risk of haemorrhage. This method
of acting is founded on a groundless fear, and is often attended
with bad consequences, which, not being supposed to flow from
this cause, are not set to its account.
The fear of haemorrhage from the divided vessels, if the omen"
tum be cut in a sound part, and the apprehension of mischief
likely to ensue from the shedding of sanies or matter into the
belly, if the division be made in the diseased, gave lise to the
A TREATISE ON RUPTURES. 361
practice of tying it before amputation; but neither one nor the
other of these apprehensions is well-grounded, nor are they
sufficient reasons for such practice.
The fear of haemorrhage is almost if not perfectly without foun-
dation, as I have several times experienced; and the discharge of
a fluid of whatever kind from the border of the divided membrane,
is of no consequence at all; neither would the ligature prevent it
if it was, as must appear to every one who will give the subject
one moment's serious consideration.
But this is not all: I am sorry to say that 1 am by experience
convinced, that making a ligature on the caul is not only unne-
cessary, but frequently pernicious, and sometimes even fatal.
A mere theoretical consideration of the parts will convince any
one of the probability of mischief arising from such practice; but,
besides these considerations, I can take upon me to say, that I
have seen it add to the hazard of the case, and more than once
destroy the patient. I have seen the omentum become diseased,
and gangrenous in all its extent above the ligature, between it and
the stomach, when it was not gangrenous at all before it was tied;
but on the contrary, in a sound state, and only tied in order to its
being more securely retrenched. I have seen a whole train of
bad symptoms, such as nausea, vomiting, hiccough, fever, anxiety,
restlessness, great pain in the belly, and an incapacity of sitting
upright, or even of moving without exquisite pain, precede the
death of a man, whose omentum was lied merely because of its
enlargement, whose intestines uninterruptedly, from the time of
the operation to his last hour, performed their proper office of dis-
charging the faeces, and were found perfect and untainted after
death, but whose omentum appeared in a highly inflammatory
state in general, and in many parts above the ligature gangrenous.
The direction given by many writers to put the patient's body
in motion, or to give him a kind of shake, in order to set to rights
the disturbance and derangement produced by tying the caul,
would be too absurd to mention, did it not serve to prove, that
even the very people who have persisted in this pernicious prac-
tice were themselves sensible of some of its probable ill conse-
quences, though they would not try to remedy them: they thought,
that those which might follow from hcemorrhage, or the discharge
VOL. T. 7. 7.
362 ■ A TREATISE OJS' RUPTURES.
of sanies, were still greater, but made no experiment, in order to
know whether they were or not.
~ I will not pretend to say, that there never was a dangerous or
fatal flux of blood, from the division of the omentum, without
ligature: but 1 can truly say that I never saw one; that I have se-
veral times cut off portions of it, without tying, and never had
trouble from it of any^ kind, though I have always made the.. eX"
cision in the sound part; and that, from the success which has at-
tended it, I shall always continue to do so, whenever it shall be-
come necessary. Upon the whole, I cannot help thinking the
ligature both unnecessary and pernicious, and can venture from
experience to say, that any portion of the caul, which it may be
thought necessary to remove, may very safely be cut off, without
any previous tying.
The best and safest method of performing this operation, is '
with a good pair of straight scissors, having first expanded it, as
well on account of its more easy division, as to prevent the mis-
chief which would attend the cutting a piece of intestine, if it should
chance to be wrapped up in it; and if any fear slill remains of
haemorrhage, the excision may, in the case of mortification, be
made just within the altered part of it; in which case, there will
no more be left to be cast off, than ther^ must be when a iigaiure
is made.
If the gangrene, or sphacelus has taken possession of the in-
testine, and consists of a small spot only, which, by casting off,
might endanger the shedding its contents into the belly, the me-
thod of endeavouring to prevent that inconvenience is by con-
necting the upper part to the wound by means of a needle and
strong ligature: by this means, when the mortified part separates,
the faeces are discharged by the wound for some time; after which
it has been known to contract gradually, and heal firmly: but
whether the event prove so happy or not, this method of securing
the gut should never be omitted.
In making this artificial attachment of the intestine to the in-
side of 'he belly, care must be taken not to wound the gut; the
needle must be passed through the mesentery, at a small distance
from the intestine, and such a portion of that body included with-
in the stitch, as shall be likely to hold fast long enough to render
A TREATISE ON RUPTURES. 363
the connexion probable. If the altered portion of the gut be of
such extent as to require excision, but yet not so large as to pre-
vent the extremities of the divided parts from being brought into
contact with each other, their union must be endeavoured by su-
ture. In doing this, the ends of the intestine should be made to
lay somewhat over each other, by which means the suture will be
the stronger; and when the two ends are thus sewed together,
they must both be fastened to the inside of the belly, at the upper
part of the wound, that in case the union does not take place, the
discharge of faeces may, if possible, be made through the groin.
But if the disease be of such extent as to prohibit the bringing
the two ends together, the treatment must be different. In this
case, as it is impossible to preserve thecontinuity of the intestinal
canal, the aim of the surgeon must be to prevent the contents of
it from being shed into the belly, and to derive through the wound
in the groin all that which should, in a sound and healthy state,
pass off by the rectum and anus.
To accomplish this, he must take care that neither extremity
of the divided intestine slip out of his fingers; then with a proper
needle, and a strong ligature, he must connect both of them to the
upper edge of the wound. The suture, wiih which the connexion
is made, must not be slight, lest it cast off before a due degree of
adhesion is procured; and it must also be made in such a manner
as to preserve the mouth of the gut as free and as open as may be,
upon which the patient's small remaining chance does in some
measure depend. The method advised by La Peyronie, of stitch-
ing the mesentery instead of the intestine, is judicious and right.
The dressing in this case should be as soft and as light as pos-
sible, nothing heavy, nothing crammed in, nothing which can ir-
ritate or give pain; and the patient must observe the most rigid
severity of diet, and the most perfect quietude both of body and
mind. With regard to medicine, whatever is exhibited must be
calculated to procure rest and ease, to quiet the febrile heat, to
keep the body open, and, if necessary, (as it most frequently must
be,) to resist putrefaction. All the rest must be left to nature,
who is by her great Creator furnished with such powers, as
sometimes to produce wonderful effects, even in these deplorable
cases.
364 A TREATISE ON RUPTURES.
This is the substance of the best practice, and of the most ap-
proved doctrine, in these circumstances, and which has sometimes
been attended with a fortunate event; but the practitioner who is
so situated as to see but little of this kind of business, ought to be
apprised how very little reason there is to hope for, or to promise
success.
More censure is incurred by an unguarded prognostic, than by
a successful event, if properly and judiciously foretold; and if a
man were to form his judgment upon this, and some other hazard-
ous disorders, from books only, he would expect very little of that
trouble and disappointment, which he will most certainly meet
with in practice.
Writers in general are too much inclined to tell their successes
only, and are fond of relating cases of gangrene and mortification,
in which large portions of intestine have been removed, the proper
operations performed with great dexterity, and in which the events
proved fortunate; and of this they all give us instances, either from
their own practice, or that of others, or perhaps sometimes from
imagination; by which the young reader is made too sanguine in
his expectation.
That these extraordinary successes do sometimes happen, is be-
yond all doubt; and it is every man's duty to aim at the same by
all possible means: but still the inexperienced practitioner should
also be informed, how many sink for one that is recovered, and
how many favourable circumstances must concur, with all his
pains, to produce a happy event in these ve.'-y deplorable cases.
Without this caution, he will meet with very irksome disappoint-
ments; and, having been often baffled, where he thought he had
good reason to expect success, he will sometimes meet with it so
very unexpectedly, that he will be inclined to believe the sarcasti-
cal distinction between cures and escapes not ill-founded.
To say the truth, the hazard is so great, and the utmost powder
of art so little, that what lapis said to iEneas with relation to his
cure, may with great propriety be said here:
Non hsec humanis opibus, non arte magistra.
Proveiiiunt ; neque te .Enea mea dextera servat ;
Major agit Deus.
A TREATISE ON RUPTURES. 365
SECT. VIL
The portion of intestine, or omentum, which composed an her-
nia, being replaced while sound and unhurt either by inflammation
or gangrene, it had always till very lately been supposed, thai if a
new descent of them were prevented by the immediate application
of a bandage, no mischief would be likely to ensue; and that, while
the iruss executed its office properly, the patient would be thereby
free from danger.
But, within these few years, it has by some of the French writ-
ers been said, that the hernial sac may be so loose and unconnected
with the spermatic chord, that it may be returned into the belly,
while it contains a portion of the intestine, labouring under a stric-
ture made by the neck of the said sac; and of this they have given
instances of cases — or of what appeared to them to be so.
Mr. Le Dran tells us, that, in one of these, the rupture was with
some difficulty returned, but, the symptoms nevertheless conti-
nuing, the patient died; and that, upon opening the body, he found
the hernial sac, including a considerable portion of intestine, re-
turned into the belly; and that the stricture made by the neck of
the sac, bound so tight, that he could not disengage the gut from it
without cutting it. His words are: —
" Nous trouvames dans le ventre le sac herniare, qui avoit trois
" pouces de profondeur, sur huit pouces de circonference, et dans
" ce sac etoit encore enfermee une demie aulme de Pintestin
"jejunum. Tenant le sac a pleine main, je voulus en faire sortir
" Pintestin, en le tirant par Pun des bouts; mais la chose me fut
" impossible, tant Pentree du sac etoit reserree, et je n'en vins au
" bout qu'en dilatant cette entree avec les ciseaux," &c.
In De la Faye's notes on Dionis, may also be seen an instance
of this kind of case, or at least of what was taken for such.
I have already given my opinion concerning the practicability
of returning a hernial sac back into the abdomen, after it has been
out any considerable length of time. I never saw, either in the
dead or the living, any reason to suppose it possible: the assertions
of these gentlemen are very positive, and I must leave the reader to
judge of them as he can»
366 A TREATISE ON RUPTURES.
The straitness of the neck of the sac is supposed to be produced
by the pressure of ihe bolster of a truss, worn to keep the parts from
descending. This part of the supposition is probable: but, it must
also be considered, that the same pressure must almost necessarily
occasion adhesions of the ouiside of the sac to the surrounding
cellular membrane; and, if we were to suppose the sac loose and
unconnected in every other part, (a thing, I must own, I never
saw,) yet this alone would for ever prevent its return into the
belly.
It is indeed represented as a circumstance not very frequently
occurring, which is fortunate for mankind; as it can neither be
foreseen nor prevented, and would add considerably to the hazard
of ruptures.
It is said, that, by carefully attending to the manner in which
a rupture goes up, we may distinguish whether the sac returns
with it or not; that if it does, including the gut, a hard body will
be perceived to pass under the finger, and that the intestine, in its
passage through the abdominal opening, will not make that kind
of guggling noise which it is usuall) found to do, when the sac does
not return with it. This, instead of being the characteristic mark
of the return of the sac, will almost always be found to be the case
when a portion of omentum which has been much compressed,
goes up at the same time with the gut; and therefore, however
ingenious this observation may seem, considered theoretically, it
is not to be depended upon in practice.
But supposing we had some clear and undoubted marks, by
which we could always know when this was the case, 1 do riot
see how we could avail ourselves of them: the intestine must be
returned before we can have our information; and if, instead of the
uncertain, delusive reasons just given, we had the clearest and
most satisfactory marks of what is suspected, we have no remedy.
but a very perplexing, tedious, and painful operation, which, I
fancy, as few surgeons would in these circumstances choose to
perform as patients submit to
I call these marks or symptoms, which these gentlemen have
given us, doubtful and delusive, because they do not with any
degree of certainty indicate the cause to which they are owing, or
from which they arise; for the inflammation excited in the intes-
tine by its having been engaged lor some lime in a stricture, will
A TREATISE ON RUPTURES. 367
sometimes produce all the same complaints after its return: but
no chirurgical operation will relieve them.
In the common reduction therefore of an intestinal rupture by
the hand', I do not see how we can avail ourselves of this supposed
discovery; and when the operation by the knife becomes necessary,
it can be of no consequence at all; for if the operation be properly
performed, the hernia! sac will be divided through its whole length,
before the instrument reaches the tendon; arid therefore the gut
can never be returned, while bound by any stricture from the
former.
It has indeed been said, that till this discovery was made, the
stricture of the abdominal tendon, and the adhesion of the con-
tents of the hernial sac to its sides, were the only known reasons
why any rupture should be irreturnable; and that when such case
occurred, if the tendon only was divided, and the sac reduced
unopened, the patient might .be lost, notwithstanding all that had
been done. To this I can only say, that a stricture, made by the
sac only, is far from being a thing unknown, and is one of the
principal reasons why all judicious writers and practitioners have
advised it to be always divided; and when this is properly execut-
ed, no such consequences can follow, even if the hernial sac
should be (what I have never yet seen) capable of being returned
into the belly.
SECT. VIII.
Ruptures through the openings of the tendons of the oblique
muscles in females are subject to the samesjmptoms, and require
nearly the same general treatment, as the inguinal ruptures of
males; and, like them, frequently admit of perfect cure, if not
mismanaged or neglected at first: the same kind of truss is also
necessary, and the same cautions with regard to the manner of
wearing it.
The open texture of the cellular membrane surrounding the
spermatic vessels, and the laxity of the scrotum, render the hernial
368 A TREATISE ON RUPTURES.
tumor much larger in males than it can well be in females: neither
can it descend so low in the latter, as it does frequently in the
former, for reasons which are obvious.
The female hernia, if recent, has much the same appearance
as the bubonocele in man; and when more of the gut or caul is
thrust forth than will lie conveniently in the groin, it pushes down
into one of the labia pudendi, and sometimes forms a tumor of
pretty considerable size.
When easily reducible, like that of men, it gives but little pain,
and generally returns into the belly upon going to bed, or upon
the patient being laid in a supine posture. When it is bound by
the opening of the abdominal tendon, and is therefore difficult, or
incapable of reduction, it is attended with the same symptoms as
the incarcerated hernia in man, and requires the same general
treatment, of bleeding, clysters, purges, warm bath, &c. and (these
failing) the chirurgic operation; by which the hernial sac is laid
open, and the stricture made by the tendon, divided.
In males, the cellular membrane which surrounds the sperma-
tic vessels and the hernial sac is generally so thickened by dis-
tention, as to take some little time to cut through, and proves
thereby a kind of security to prevent the sac from being too
hastily opened; but in females it should be remembered, (hat the
hernial bag lies immediately under the membrana adiposa, and
requires to be very cautiously divided, on account of its contents:
nor have I in general observed the fluid contained in the hernial
sac of females to be equal to that which is found in males.
The piece of intestine which is strangulated in the female
bubonocele is sometimes so small, as to occasion very little tumor;
and therefore, if recent, is very often, in modest women, not
known to be the cause of the symptoms which it produces. If by
accident it returns back before it is hurt in its texture, the disease
passes for a colic; if it proves fatal by mortification, it is taken for
a passio iliaca, or miserere. The means made use of for the relief
of either of those diseases, being such as will not, in general,
without the assistance of a surgeon's hand, procure a return of
the protruded gut, many an useful life has been lost by the real
cause of the mischief not being known. Every symptom (the
tumor excepted) which accompanies a rupture labouring under
A TREATISE ON RUPTURES. 369
stricture, may attend a passio iliaca; that is, an inflammation and
obstruction to the execution of the office of the intestine, whether
produced by the stricture of the abdominal tendon, or the spas-
modic contraction of its own muscular fibres, will be attended
with the same kind of symptoms: but though the general means
of relief are alike in both cases, yet the former requires also the
assistance of a surgeon's hand to replace the piece of intestine, or
all the rest will be absolutely ineffectual: if that be neglected, the
case in general will end ill, and though the mischief is set to ano-
ther account, and supposed to have been without remedy, yet it is
very certain that timely assistance would very frequently prevent
such bad consequences. It therefore behoves every medical man,
who may be called to women labouring under such complaints, to
be very attentive to them; and if the symptoms run high, never to
omit inquiring whether there be any tumor in the groin, belly, or
pudenda; and if there be such, to be informed of what nature it is,
before he goes any further, or loses any more of that time, which
in all these cases is so very precious.
In the case of the dolor colicus, the pain is either round about
the navel, or diffused in general all over the belly: that arising
from i strangulated rupture is also very frequently general all over
the belly, but is always more particularly acute at the groin, which
part is also remarkably tender to the touch. The tension of the
belly, and the vomiting in the passio iliaca, are in general the first,
at least they are very early symptoms; whereas they do not come
on in ruptures, till after some time is past. Perhaps some other
minute distinctions might be made between the apparently similar
symptoms of the two diseases: but the best and most infallible
way to know what the real state of the ease is, and thereby what
ought to be done, is to have the parts examined where such tumor
may be expected. This removes all doubt, and gives the practi-
tioner the satisfaction of knowing, that, let the consequence be
whatever it may, he is pursuing a rational and probable method of
relieving his patient.
VOL. 1.
370 A TREATISE ON RUPTUREi,'.
SECT. IX.
The crural, or femoral hernia, receives its name from its situa-
tion, tiie tumor occasioned by it being in the upper and fore part
of the thigh.
To understand rightly the nature and situation of a crural rup-
ture, it is necessary to attend to the anatomical structure and dis-
position of the obliquus descendens .muscle of the abdomen.
Whoever does this, will find that that part of it which runs obli-
quely downward from the spine of the os ilion, towards the sim-
physis of the os pubis, is tucked down, and folded inward, as it
were. This edge or border, so folded in, is what is called the
ligamentum Poupartii by some, by others the ligamentum Fallopiij
as if it was a distinct and separate body, but is really no more
than the inferior border of the tendon of the oblique muscle. In
all the space between these two attachments, this tendon is loose
and unconnected with any bone. All the hollow, which is made
by the form of the os ilion, between the point of the attachment of
the ligament or tendon to that bone, and its other connexion, at the
os pubis, is filled up by cellular membrane, fat, and glands; which
parts are covered, and braced down, by a fine tendinous expansion,
communicating between the tendon of the obiiquus descendens
abdominis and the fascia lata of the thigh.
Under this tendon, or ligament, the parts composing a hernia
pass, and produce a tumor on the upper and fore part of the thigh.
The sac is generally described as passing over the crural artery
and vein, which are said to lie immediately behind it; but whoever
will examine the state of these parts in a dead subject, will find
that this is not a true representation: the descent is made on one
side of these vessels, nearer to the os pubis; and the hernial sac,
if it be not greatly distended, lies between the crural vessels and the
last mentioned bone, on which it rests.
The femoral hernia is not so subject to stricture as the inguinal,
there being a larger space for the intestine to occupy: but when
such mischief does happen, the symptoms are so exactly the same
as they are in a strangulated inguinal hernia, that it is quite uiine-
A TREATISE ON RUPTURES. 371
ccssary to repeat them in this place. The method of attempting
reduction, and the treatment of the patient in case of difficulty, are
the same also; excepting that, in the inguinal, tlic part to be reduc-
ed should be pressed obliquely toward the os ilion; in the femoral,
the pressure ought to be made directly upward, or a little toward
the pubes.
When it is not reducible by the hand only, it, like the other,
becomes the object of a chirurgic operation, by which the sac is
laid open, the stricture removed, and the prolapsed parts returned.
The incision should be made through (he skin, and membrana
adiposa, the whole length of the tumor: under these will be seen
the tendinous fascia, or expansion, and immediately under that
the hernial sac. These being carefully divided, and the poriion
of intestine thereby denuded, it is well worth while to try if it can-
not be returned without dividing the tendon, as there is a con-
siderable space between the os ilium and the os pubis, to manage
such reduction in, and as the division of the tendon is not always,
in this kind of rupture, so safely executed. In ihis there are two
parts of consequence, which lie very little out of the way of the
knife, and which an operator should avoid wounding: these are
the epigastric artery, and the spermatic chord. If the division of
the ligament be made directly upward, the spermatic chord will
certainly be divided; and if, to avoid that, the knife be carried
very obliquely towards the os ilium, the artery will meet with the
same fate; and indeed if the incision of the ligament be made of
any length, let it be made in whatever part it may, the risk will
be great of wounding one of the parts just mentioned, as will ap-
pear to any body who will examine them in situ naturally and
make a proper allowance for the pressure and distention of the
hernial sac.
Of the two, the spermatic chord is certainly the most to be re-
garded, as the total division of it would, in all probability, render
the testicle on that side useless. If the artery be wounded, it must
be taken up with a needle and ligature; but the doing is not so
easy as the directing it to be done: the epigasti"ic artery in many
men is near as large as the smaller carpal; departs immediately
from the trunk of the crural, and, at its origin, lies in a bed of fat
and cellular membrane; the stream of blood would be pretty brisk,-
3tJSI A TREATISE ON RUPTURES.
and the passage of the needle round would certainly be trouble-
some, if not hazardous, from the vicinity of the crural vessels. It
may undoubtedly be happily executed; but, as it must be aaencied
with a good deal of trouble, and some risk, it is much belter to
avoid the necessity, which I think may always be done, consider-
ing the large space between the os ilion and the os pubis, and that
the space is occupied principally by cellular membrane and fat:
or if the division of the ligament be unavoidable, let the operator
be particularly careful to keep the extremity of the probe-pointed
knife within the end of his fore-finger, held up tight just behind
the edge or border of the tendon, and to make as small an incision
as may be necessary: the probe-scissors, the common instrument
in use for this operation, is in this case particularly hazardous and
improper.
In all other circumstances, this hernia, and the inguinal, are so
similar as to need no repetition.
SECT. X.
THE CONGENIAL HERNIA.
The congenial hernia, as it is now called, is that particular
kind of hernia, in which the portion of intestine, or omentum,
which occasions the tumor, instead of being found alone in the
hernial sac, (as in a common rupture,) is found in contact with the
naked testicle; the bag containing it being formed by the tunica
vaginalis testis.
The manniMi in which a common hernial sac is formed, has al-
ready in a former chapter been related, viz. by the thrusiing forth
of a portion of the peritoneum though the opening in the tendon
of the external oblique musclf- of the abdomen; which portion, so
thrust forth, contains a piece of intestine, or omentum, or both. A
hernial sac thus formed, always communicates with the caviiyof
the belly, but never with that of the tunica vaginalis testis. It
A TREATISE ON RUPTURES. 373
passes clown anterior to the spermatic chord; and, when it is laid
optrMi, is found to contain only a portion of gut, or caul, and a small
quantity of fluid.
On the contrary, the sac of a congenial hernia is formed by the
tunica vaginalis testis itself; and, whf;n it is laid open, (whatever
else may be in it,) it is always found to contain the testicle,
covered only by its proper coat, commonly called tunica al-
buginea.
The manner in which this is brought about, the original or early
situation of the testes in a foetus, their descent, their protrusion from
the cavity of the belly, and the formation of the tunica vaginalis
testis, I have described so much at large in two tracts already
published,^ that I shall give a very short account of them in this
place.
That bag which is designed to make the future tunica vaginalis
testis, is an originally formed part, lies in the groin, under the skin-
and adipose membrcyie, and has an orifice always open to the ab-
domen of a foetus. By means of this orifice, the testicle at proper
time descends into the groin first, and then most commonly into
the scrotum; and, when it has been some little time in the latter,
the opening from the belly generally becomes close, and is oJiIite-
rated. Bv the closing of this passage, a bag or cavity is formed,
which contains within it the testicle, covered only by its tunica
albuginea, and which bag never afterward has any communication
with the orifice into the cavity of the belly.
The time at which the testicles are thrust forth from the belly is
very uncertain, as I have often experienced; and so is that of the
absolute closing of the sacculus. In some they pass out before birth,
in some immediately after, and in some not till som_e time after; in
some they never pass out at all, and in others, they (that is, the
two) arrive in the groin, or scrotum, at different, and sometimes
very distant times. In short, the intention of nature, and her pro-
cess, is in general regular and plain, but it is accomplished at dif-
" An Account of the Congenial Hernia, published in 1757 ; and some Ob-
servations on the Hydrocele, published in 1762. In Dr. Hunter's Medical
Comment, No. 1, may also be seen a very ingenious account of tliis matter, by
his brother Mr. John Hunter,
374 A TREATISE ON RUPTURES.
ferev)f periods in different persons; and sometimes, like most other
parts of the animal economy, it is totally prevented by accident, or
malformation.
The intrusion of a piece of intestine, or omentum, into the ori-
fice of the tunica vaginalis, is one of these accidents. By means
of either of these, the closing of the passage is prevented, and a
hernial sac of a particular kind formed. This sac being really the
vaginal coal of the testis, must, if that body has fallen from the
abdomen, contain the intestine, omentum, or whatever forms the
hernia and the testicle in immediate contact with each other.
This is the congenial hernia; a disease unknown till within these
few years, but by no means an infrequent one.
The appearance of a hernia in very early infancy will alwa3'S
make it probable that it is of this kind; but in an adult, there is
no reason for supposing his rupture to be of this sort, but his hav-
ing been afflicted with it from his infancy: there is no external
mark or character, whereby it can be certainly distinguished from
one contained in a common hernial sac; neither would it be of
any material use in practice if there was.
When reiurnable, it ought like all other kind of ruptures to be
reduced, and constantly kept up by a proper bandage; and when
attended with symptoms of slricture, it requires the same chirurgic
assistance as the common hernia.
In very young children, there are some circumstances relative
to this kind of rupture, which are very well worth attending to,
as they may prove of very material consequence to the patient.
A piece of intestine, or omentum, may get pretty low down in
the sac, while the testicle is still in the groin, or even within the
abdomen; both which I have seen. In this case, the application
of a truss would be highly improper; for in the latter, it might
prevent the descent of the testicle from the belly into the scrotum:
in the former it must necessarily bruise and injure it, give a great
deal of unnecessary pain, and can prove of no real use. Such
bandage therefore ought never to be applied on a rupture in an
infant, unless the testicle can be fairly felt in the scrotum, after
the gut or caul is replaced; and when it can be so felt, a truss can
never be put on too soon.
As this kind of rupture is subject to stricture with all its con-
A TREATISE ON RUPTURES. 375
sequences, as much as that wliicli is contained in a common her-
nial sac, and therefore liable to stand in need of the chirurgic
operation: it may be very well worth an operator's while to know,
that an old rupture, which was originally congenial, is subject to
a stricture made by the sac itself, independent of the abdominal
tendon, as well as to that made by the said tendon.
Whether this be owing to the weight of the tesiicle at the bot-
tom of the sac, and the endeavours which nature makes to close
the upper part of the tunica vaginalis, or to what other cause, I
will not pretend to say; but the fact I have several times noticed,
both in the dead and in the living. 1 have seen such stricture
made by the sac of oneof these hernise, as produced all those bad
symploms wiiich render the operation necessary; and I have met
with two diiferent strictures, at near an inch distance from each
other, in the body of a dead boy about fourteen, one of which
begirt the intestine so tight that I could not disengage it without
dividing the sac.
In this kind of hernia I have also more frequently found con-
nexions and adhesions of the parts to each other, than in the com-
mon one; but there is one kind of connexion sometimes met with
in the congenial hernia, which can never be found in that which
is in a common hernial sac, and which may require all the dex-
terity of an operator to set free; I mean that of the intestine with
the testicle, from which I have more than once experienced a good
deal of trouble.
When a common hernial sac has been laid open, and the intes-
tine and omentum have been replaced, there can be nothing left in
it which can require particular regard from the surgeon; but by
the division of the sac of a congenial hernia, the testicle is laid
bare, and after the parts composing the hernia have been reduced,
will require great regard and tenderness, in all the future dress-
ings, as it is a part very irritable, and very susceptible of pain, in-
flammation, &c.^
3 The method of bringing' the parts together, and retaining them so as to
exclude the air, (mentioned in a former note, in this volume,) is equally ap-
plicuble to cases of congenial hernix ; and as it will prevent tlie exposure of
the testis, all future dressings of it will he unnecessar}'.
$76 A TREATISE ON KUPTUREfe',
If a large quantity of fluid shoul(3 be collected in the sac of a
congenial hernia, and, by adhesions and connexions of the parts
within, the entrance into it from the abdomen should be totally
closed, (a case which I have twice seen,) the tightness of the
tumor, the difficulty of distinguishing the testicle, and the fluctua-
tion of the fluid, may occasion it to be mistaken for a common
hydrocele; and if, without attending to other circumstances, but
trusting merely to the feel and look of the scrotum, a puncture be
hastily made, it may create a great deal of trouble, and possibly do
fatal mischief.
By what has fallen within my observation, I am inclined to
believe that the sac of a congenial hernia is very seldom, if ever,
distended to the degree which a common hernial sac often is: it
also, from being less dilated, and rather more confined by the
upper part of the spermatic process, generally preserves a pyriform
kind of figure, and, for the same reason, is also generally ihinnerj
and will therefore require more attention and dexterity in an ope-
rator when he is to open it. To which I believe I may add, that
common ruptures, or those in a common sac, are generally gradually
formed; that is, they are first inguinal, and by degrees become
scrotal: but the congenial are seldom, if ever, remembered by the
patient to have been in the groin only.
SECT. XI.
EXOMPHALOS.
The Exomphalos, or Umbilical rupture, is so called from its
situation, and has, like the other, for its general contents, a por-
tion of intestine, or omentum, or both. In old umbilical ruptures,
the quantity of omentum is sometimes very great.
Mr. Ranby says, that he found two ells and a half of intestine in
one of these, with about a third part of the stomach, all adjiering
together.
A TREATISE ON RUPTURES. 377
Mr. Gay and Mr. Nourse found the liver in the sac of an umlji-
lical hernia; and Bohnius says that he did also.
But whatever are the contents, they are originally contained
in the sac, formed by the protrusion of the periioneum.
In recent, and small ruptures, this sac is very visible; bu* in
old, and large ones, it is broken through at the knot of the n.vel,
by the pressure and weight of the contents, and is not always to.
be distinguished; which is the reason why it has by some been
doubted whether this kind of rupture has a hernial sac or nol.
Infants are very subject to this disease, in a small degree, from
the separation of the funiculus; but in general they either gel rid
of it as they gather strength, or are easily cured by wearing a pro-
per bandage. It is of still more consequence to get this disorder
cured in females, even than in males, that its retuin, when they ■
are become adult, and pregnant, may be prevented as much as
possible; for at this time it often happens, from the too great dis-
tention of the belly, or from unguarded motion when the parts are
upon the stretch. During gestation it is often very troublesome;
but after delivery, if the contents have contracted no adhesion,
they will ofteti return, and may be kept in their place by a proper
bandage.
If such bandage was always put on in time, and worn con-
stantly, the disease might in general be kept within moderate
bounds, and some of the very terrible consequences which often
attend it might be prevented. The woman who has the smallest
degree of it, and who from her age and situation has reason to
expect children after its appearance, should be particularly care-
ful to keep it restrained.
In some the entrance of the sac is large, and the parts easily
reducible; in others they are difficult, and in some absolutely ir-
reducible. Of the last kind many have been suspended for years
iii a proper bag, and have given little or no trouble. They who
are afflicted with this disorder, who are advanced in life, and in
whom it is large, are generally subject to colics, diarrhoeas, and,
if the intestinal passage be at all obstructed, to very troub-esorae
vomitings.- It therefore behoves such to take care to keep that
^ On Mihich account they are often supposed to labour under a Rtriottire nf
the intestine, when tbey reallv do no^
VOL. J. 3 8
376 A TREATISE UN RUPTORES.
tube as clean and free as possible, and neither to eat nor drink any
thing likely to make any disturbance in that part.
The cure, as proposed by authors, is either radical or pal-
liative.
Celsus, Paulus iEgineta, Albucasis, Aquapendens, Guido, Se-
verlnus, Roland us, and others, mention a radical cure by ligature:
Fab. ab Aquapendente proposes, " aut medicamentis aut ferro
*' umbilicum adurere;" but after having described both methods,
lie lays them under such restraints, from age, habit, size of the
tumor, time of the year, &,c. as amounts almost to a prohibition
against putting them in practice at all; and it is to be hoped that
nobody will attempt to revive them.
The methods by ligature are two; in the one, the skin covering
the tumor is to be lifted up with the finger and thumb, or with a
small hook to free it from the intestine underneath; and then a
ligature is to be made round the basis of the tumor, so strict as to
procure a mortification of all that part which is anterior to such
ligature. In the other, the skin is to be elevated in the same
manner, and a needle armed with a double ligature is to be passed
through the basis of the tumor, which is to be tied above and be-
low, or on each side, so tight as to produce the same effect. Pre-
vious to the drawing the ligature close, it is advised to make a
small incision in the top of the tumor, large enough to pass in the
end of the fore-finger, and with it so to depress the intestine or
omentum, as to prevent their being engaged in the stricture.
The intention in both these methods is the same; viz. by de-
stroying the lax skin covering the top of the tumor, to produce a
cicatrix which shall bind so tight as to restrain the parts from any
future protrusion.
The objections to either of them are so obvious, that it is hardly
necessary to say any tiling concerning them; though, in this age of
quackery and credulity, I should not wonder to see them revived
and practised.
In young subjects, and small hernias, a bandage worn a proper
time generally proves a perfect cure; and in old persons, and
large tumors, it is hardly to be supposed that any body can think
of any but a palliative one, the hazard of producing a mortifica-
tion being so great.
A TREATISE ON RUPTURES. 379
But suppose the subject to be young, and the tumor of such size
and in such state as to make it unUiaHly that a bandage would do
more than palliate; that the skin covering the tumor is so lax, as
to make it improbable that it should ever recover its former state,
and lie smooth; and that, when it has been removed, the cicatrix
shall bind so tight, as to prevent the future protrusion of any of
the contained parts; yet who can tell what may be the conse-
quence of this destruction of parts, and this indilatability of the
skin in a state of pregnancy? I mention this, because I have seen
very terrible mischief from the bursting of a cicatrix on the navel,
during gestation; though the scar was from an abscess, opened by
incision, and consequently could not be supposed to be equal, either
in size or resistance, to one produced by the fore mentioned ope-
ration.
The umbilical, like the inguinal hernia, becomes the subject of
chirurgic operation, when the parts are irreducible by the hand
only, and are so bound as to produce bad symptoms. But though
I have in the inguinal and scrotal hernia advised the early use of
the knife, I cannot press it so much in this; the success of it is
very rare, and I should make it the last remedy. Indeed I am
much inclined to believe, that the bad symptoms which attend
these cases are most frequently owing to disorders in the intestinal
canal, and not so often to a stricture made on it at the navel as
is supposed. I do not say that the latter does not sometimes bap-
pen — it certainly does; but it is often believed to be the case when
it is not.
When the operations become necessary, it consists in dividing
the skin and hernial sac, in such manner as shall set the intestine
free from stricture, and enable the surgeon to return it into the
abdomen, if found, and not adherent; but if it be gangrenous, or
mortified, the altered part must be removed, and the faecal dis-
charge be derived through the wound; by which means, some
few have preserved their lives, if such state can be called living.
380 A TREATISE ON RUPTURES.
t
SECT. XII-
VENTRAL HERNIA, &t.
This may appear in almost any point of the fore part of tlie
belly, but is most frequently found in or between the recti mus-
cles.
The portion of intestine, &c. is always contained in a sac,
made by the protrusion of the peritoneum. When reduced, it
should be kept in its place by bandage; and if attended with
stricture, which cannot otherwise be relieved, that stricture must
be carefully divided.
The hernia foraminis ovalis I have never seen.'=
All the parts almost which are contained in the belly or pelvis,
are, by the dilation of iheir connecting membranes, capable of
being thrust forth, and of producing swellings, all which are called
herniaB.
Ruysch gives an account of an impregnated uterus being found
on the outside of *he abdominal opening; and so does Hildanus
and Sennertus. Ruysch also gives an account of an entire spleen
having passed the tendon of the oblique muscle. And I have
myself seen the ovaria removed by incision, after they had been
some months in the groin.
The urinary bladder is also liable to be thrust forth, from its
proper situation, either through the opening in the oblique muscle,
like the inguinal hernia, or under Poupart's ligament, in the
same manner as the femoral.
This is not a very frequent species of hernia, but does happen,
and has as plain and determined a character as any other.
It has been mentioned by Bartholin, T. Dom. Sala, Platerus,
e Since Mr. P. wrote this, be informed me that he had seen two cases of this
kind, one in a man, another in a woman; in botli, the pai-ties suffered great
pain when the intestine was protruded, as it frequently was to the size of a
hen's egg, but by lying in a horizontal posture, and a gentle pressure being
made, it receded. E.
A TREATISE ON RUPtURES. 381
Bonetus, Ruysch, Petit, Mery, Verciier, &c. In one of the histo-
ries given by the latter, the urachus, and ini|)ervious umbilical
artery on the left side, were drawn through the tendon into the
scrotum, with the bladder; in another he found four calculi.
Ruyscb gives an account of one complicated with a mortified
bubonocele. Mr. Petit says he felt several calculi in one, which
were afterwards discharged through the urethra.
Bartholin speaks of T. Dom. Sala as the first discoverer of the
disease, and quotes a case from him in which the patient had all
the symptoms of a stone in his bladder: the stone could never
be felt by the sound, but was found in the bladder (which had
passed into the groin) after death .'*
As the bladder is only covered in part by the peritoneum, and
must insinuate itself between that membrane and the oblique
muscle, in order to pass the opening in the tendon, it is plain that
the hernia cystica can have no sac; and that, when complicated
with a bubonocele, that portion of the bladder which forms the
cystic hernia must lie between the intestinal hernia and the sperma-
tic.chord; that is, the intestinal hernia jnust be anterior to the cystic,
A cystic hernia may indeed be the cause of an intestinal one;
for when so much of the bladder has passed tlie ring as to drag
in the upper and hinder part of it, the peritoneum which covers
that part must follow, and by that means a sac be formed for the
reception of a portion of gut or caul. Hence the different situa-
tion of the two hernice in the same subject.
<• Many years ago a boy, about ten years of'ag'e, was siiov.'n to jMv. PoU,
with a hard incompressible tumor in the upper part of the scrotum on the
right side, which gave little pain except when pressed on. To determine
positively its nature and contents was certainly a matter of no little diffl'.ult* ,
It however occurred to me that it might be a hernia of the bladder includinc;
a stone. Mr. Pott made an incision through the skin and cellular membrane
on the upper part of the tumor, which, now being denudated, more plainly
appeared to be what I had suspected. Mr. Polt then drew it forward and
divided the neck, when a stone of the size of a very large nutmeg was de-
tached covered with the bladder, except at the upper part, which was left
bare from the elastic retraction of the bladder. Some urine followed, and
continued to come away in smaller and smaller quantities ihrougli the open-
ing, till it completely closed, which happened in a few days: — without any
adverse symptoms, the boy got perfectly well. Tlie stone with its covering
of bladder is now in my possession. E.
382 A TREATISE ON RUPTURES.
While recent, this kind of hernia is easily reducible, and may,
like the others, be kept within by a proper bandage; but when it is
of any dale, or has arrived to any considerable size, the urine
cannot be discharged, without lifting up, and compressing the
scrotum: the outer surface of the bladder is now become adherent
to the cellular membrane, and the patient must be contented with
a supensory bag.
In the case of complication with a bubonocele, if the operation
becomes necessary, great care must be taken not to open the
bladder instead of the sac, to which it will always be found to be
posterior. And it may also sometimes by the inattentive be mis-
taken for a hydrocele, and, by being treated as such, may be the
occasion of great or even fatal mischief.
SECT. XIII.
ATTEMPTS TOWARDS A RADICAL CURE.
In the first section of this treatise I have said, that the means
used to obtain both a palliative and a radical cure were exactly
the same, and the event was dependent on many circumstances,
which a surgeon could neither direct nor alter; such as the age of
the patient, the date of the hernial sac, the size of the abdominal
openings, &c.
They who are unacquainted with the true nature of this disease
may possibJy be surprised at this assertion, and be thereby induced
to believe, what has in all times been so confidently asserted, viz.
that there are methods and medicines whereby this disease may
always be perfectly cured; and that the surgeons, either through
indolence will not get information of them, or through obstinacy
will not practise them. If either of these charges was true, it
must be the latter, for we certainly do know what attempts of this
kind have been made; and if any of these means had really de-
served the character which has been given of them, had been safely
A TREATISE ON RUPTURES. 383
practicable, or had proved generally successful, I should certainly
have spoken of them in their proper place: but this is so far from
being the case, that, on the contrary, however they may have been
applauded by a few individuals, they have, upon repeated expe-
riment, been found unfit for general practice, being either totally
inefficacious, or painfully mischievous. The majority, nay, al-
most all they who have submitted to, or tried them, have remained
uncured of their disease, or have been mutilated or murdered in
the attempt.
Several of these methods have indeed the sanction of antiquity,
and have been described and even practised by many of the old
surgeons: the principal of these, or they which are most worthy of
notice, are the cure by cautery; the cure by caustic; that by castra-
tion; the punctum aureum; the royal stitch; and the cure by in-
cision.
In Avicenna, Albucasis, Paulus iEgineta, Fab. ab Aquapen-
dente, Guido, De Caliaco, Severinus, Theodoric, Rolandus, Ser-
jeant Wiseman, and others, will be found the cure by cautery^
which is performed as follows:
After a proper time spent in fasting and purging, the patient
must be put into an erect posture, and by coughing, or sneezing,
is to make the intestine project in the groin as much as possible;
when the place and circumference of such projection is to be
marked out with ink. Then the patient being laid on his back,
the intestine is to be returned fairly into the belly, and a red hot
cautery is to be applied according to the extent of the marked line.
For this purpose, cauteries of different sizes, shapes, and figures,
have been devised; annular, elliptical, circular, like the Greek
letter Gamma, &c. The writers who have given an account of
this operation, have differed a good deal from each other, not only
in the size and figure of the cautery, but in depth of its effect-
Some have directed it to be repeated, so as to denude the os pubis;
others direct that the skin only be destroyed by the iron, the cel-
lular membrane, sac, periosteum, &c. with repeated escharotic
applications. . But, in all of them, the exfoliation^ of the bone is
= Albucasis says, "Et sciasquod quanclo tu non conseqneris os cum caufe-
" no, non confert operatio tua."
384 A TREATISE ON RUPTURES.
made a necessary part of the process. The eschar and sloughs
being separated, and the exfoliation cast off, the palieiil is ordered
to observe an extremely strict regimen, to lie on his back during
the cure, and to wear a bandage for some time after, in order to
prevent a new descent of the parts, which, notwithstanding all
the pain, and all the hazard, the patient had undergone, he was
still liable to.
The cure by caustic seems to have succeeded to that by cautery,
and is described by most of the same writers, particularly by
Guido, Severinus, Lanfranc, Parey, Theodoric, Scultetus, &c.
The patient being laid on his back, and the paris returned into
the belly, a piece of caustic is to be applied on the skin, covering
the opening in the abdominal tendon, so large as to produce an
eschar, about the size of half a crown.
Some suffer this eschar to separate, others divide it, and then, by
the repeated applications of escharotics, destroy the membrana
cellularis, with as much of the hernial sac as can be done without
injuring the spermatic vessels. For this purpose, different kinds
of corrosive applications have been made use of: pastes loaded
with sublimate or arsenic; the stirpes brassicae, burnt; the tithy-
malus; the lapis infernalis alone, or with suet and opium; oil of
vitriol; with many others, according to the humour of the operator.
But, though the means are somewhat different from each other,
thte end or intention in the use of them all is the same, viz. to re-
move or destroy the skin and cellular membrane covering the tu-
mor, together with a part of the hernial sac, and by that means to
procure such an incarnation, as, by its firmness, and its attachment
to the bone and parts adjacent, shall prevent a new descent of
either gut or caul.
The mere relation of one of these methods is sufficient to shock
any humane or ingenuous man. The horror attending the use of
the cautery must be great, to say nothing of the extreme uncer-
tainty of the size or depth of the eschar: the apprehension from
Rolandiis orders the cautery to be used in the same manner ; so do Guido,
Theodoric, &.c.
Bruniis says, " Si non fiierit os consccutum, in pviir a -ire, tunc itera caute-
"rium vice ah4 d^)ne& conseqiieris ; quia si noii coaseculuni fuerit os, cum
"cauterio, panrnj confert operatio tuu."
A TREATISE ON RUPTURES. 385
the caustic will be less, incieeci, but the pain must be nearly as
great, and of much longer duration.
The parts to be destroyed are, as I have just said, the skin, the
membrana adiposa, part of the hernial s«c and, the periosteum
covering the os pubis; and this is to be accomplished without in-
juring the spermatic vessels, or the tendon of the abdominal mus-
cle.
If the spermatic vessels are hurt, an inflamed or diseased tes.^
ticle will be the consequence: if they arc destroyed, the testicle
will become useless. If the tendon of the oblique muscle be in-
jured, either by the iron, or by the caustic, terrible sloughs, a
large ill-conditioned sore, and a brisk symptomatic fever, must be
expected, which in some habits must be productive of considera-
ble mischief: and that considerable mischief was often done by
these processes, may be learned from the very writers who des-
cribe them.*"
If the OS pubis be laid bare, whether by cautery or by caustic,
some of the before mentioned hazards must be incurred; if it be
not, the intention will in general be frustrated; that is, the intestine
will slip down behind the scar, and put the patient under the same
^ Guido, speaking of the cure by caustic, says, " In quo summe cavendum
" est, quod dominus sit de corrosivo ; si enim iiidocte applicatur, febrim
"coir.movet, et accidentia mala." Tl)at great pain, deflation on the he-
morrhoidal vessels, and inflammation and swelling of the scrotum, were often
the consequence of these jtttempts, may be learned from the same author,
■who, speaking of the method of applying the caustic, says, " Et ita continue
"fiat quousque caro miracis tota sit corrupla, usque ad Didymum, quod cog-
"noscitur per inflationem bursse, et tesliculorum." And that the caustic
has gone deep enough, he gives the following proof: " Quod cognoscetur
"per majorem tumorem testiculi et per majorem dolorem dorsi et partium
" posteriorum." Brunus says, "Et cave summa diligenlia, ne in hoia caute-
" rizationis exeat intestinum, et comburatur." Lanfranc, speaking of the ill
effect of the caustic in some habits, says, " Et sic multi spasmantur, et spas-
" mati subito moriuntur," Fab. ab Aquapendente says, " Qus tamen chirur-
"giae uti videtis, difficiles admodum sunt, et inter subtilissimas haberi pos-
" sunt ; quo fit ut plerique patientes afl^ectus perpetuo gestare quam his
" chirurgis submittere se vellent." And in another place, " Quae porro chi-
" rurgise vehementem dolorem afferunt et satis difficlles sunt. In short,
whoever will take the trouble of reading the old writers on this subject, will,
even from their own account, be satisfied, of the pain, hazard, and inefficacy
of all these methods.
VOL. I. 3 c
386 A TREATISE ON RUPTURES.
necessity of wearing a bandage, as lie lay under before he sub-
mitted to so painful and so hazardous an experiment.
If the preservation of life was the object of these means, some-
thing might be said in their vindication; the anceps remedium
must for ever be preferable to desperation: but that is not the
case: they are recommended to be put in practice, when the pa-
tient's life is in no kind of danger, and are designed merely to
save him the trouble of wearing a truss, which purpose they can
seldom answer; for it is well known, that after the use of the
cautery, caustic, and every method, either proposed for a radical
cure, or used to rescue a ruptured patient from death, that the
intestine will slip down behind the cicatrix, and form a new bu-
bonocele, which can only be kept up by a proper bandage.
The three other means made use of by the ancients toward ob-
taining a radical cure were, the punctum aureum, the royal stiteh,
and castration.
The punctum aureum was performed as follows: — The intes-
tines being emptied by purging and the hernia reduced, an inci-
sion was made through the skin and membrana adiposa, down to
the spermatic process. This incision was to be of such length,
as to permit the operator, either with his finger or with a hook, to
take the said process, and to pass a golden wire under it; which
wire was to be twisted in such a manner as to prevent the intes-
tine from slipping down again into the hernial sac, but not so
tight as to intercept or obstruct the circulation of the blood to the
testicle. Some operators preferred a leaden wire to a golden one,
and others a silken ligature.
It may possibly- seem rather uncivil to say, that both this and
the succeeding operation were directed and practised by people
who were very little acquainted with the true nature and structure
of the parts they operated upon, or indeed of the disease for which
they prescribed such operation: but had not that been the case,
they never could have proposed so fallacious and uncertain a
method of treating it; for if the wire or whatever was passed
round ihe process did not bind pretty tight, it would not prevent
a descent of the gut; and the whole operation, though painfiJ and
irksome, must become absoluUiy uscle'^.s: if it did bin.^. -'gi *, it
must necessupily retard hn^ otTs cuct ihe v.ii'cuh J.; •'.'^'-d
A, TREATISE ON RUPTURES. 387
through the Spermatic vessels, and produce a disease of them, and
of the testicle.^
The royal stitch was performed ia this manner: the intestines
being emptied, and the portion which had descended being re-
placed, an incision was made in such manner as to lay bare the
spermatic chord, aboui two inches in length from the abdominal
opening downward. When the process was freed from the cellu-
lar membrane, it was to be held up by an assistant, while the
surgeon with a needle and ligature made a continued suture, from
the lower part of the incision to the upper, in such manner as to
unite the divided lips of the wound again, comprehending the cel-
lular membrane, and thereby endeavouring to straighten the pass-
age, as they called it, from the belly into the scrotum, without
injuring the spermatic vessels.
The operation is described by many of the old writers,'* with
some small variation from each other, both in the m^anner and in
the instruments; but all tending to the same end, and all proving
that their ideas of the disease, and of the parts affected by it, were
erroneous and imperfect.
The fatigue to the patient must be greater in this than in the
preceding operation, both on account of the large incision, and of
the suture.
In some habits, either of them must be very hazardous, and in
the majority of cases, painful, troublesome, and tedious; which
circumstances might nevertheless be submitted to, if the cure was
certain, the contrary to which did most frequently happen, even
by the confession of the very writers who propose and describe
these methods, and who universally order the long wearing a truss
after such operations have been submitted to.
Some, who thought that the stitch added unnecessarily to the
pain, have directed the incision to be made in the same manner as
for the suture; but, instead of sewing the lips together, have ad-
vised that the common membrane be dissected out pretty clean,
g Whoever would know llie particular methods of executing this opera=
tion, may find them in G lido, Parey, Franco, Scultetus, Smaltzius, Per-
mannus, Nuck, &c.
!' Paulus, Albucasis, Fab. ab Aquapendente., Guido, Rolandus, Parey, Ser-
;ieant "Wiseman, &c. Sec. &c.
388 A TREATISE ON RUPTURES.
and the sore digested and incarncd. This is so like to the opera-
tion for the incarcerated bubonocele, both in the manner of making
the incision and in its consequence, as tending toward a radical
cure, that it may be looked upon as really the same thing; and
how very fallacious and uncertain that operation proves toward
answering this end is too well known.
Both these, ihe royal stitch and the punctum aureuni, proved
often destructive to the testicle, even in the most judicious hands;
and when it got into those of ignorant pretenders, it proved most
frequently so; for not knowing how to perform properly what they
had undertaken, and finding it much more easy, after the incision
was made, to slip out the testicle, they most commonly did so.
These are the principal methods proposed or practised by our
forefathers for a radical cure of a rupture: among the writers in-
deed will be found some trifling variations from each other in the
execution of them, but the intention and aim are the same in all,
viz. to prevent a new descent of either gut or caul, by producing
an union of the parts, through which they either did or were sup-
posed to pass. According to the degree of anatomical knowledge,
and humanity of the proposer, they will be found to be more or
less rational and gentle; but are all of them painful, hazardous,
and most frequently fallacious, and have therefore been totally
disused by all modern practitioners, who have either knowledge,
compassion, or honesty.
No disease has ever furnished such a constant succession of
quacks as ruptures have: they who have had some smattering of
anatomy or surgery, and whose humanity has not been their pre-
vailing quality, have adopted one of the preceding operations, or
something like them; while they who have had less knowledge,
and more timidity, have had recourse to the more sneaking knavery
of specific applications.
The histories of prior Cabriere, Bowles, Sir Thomas Renton,
Dr. Little John, &c. &c. &c. to be found in Dionis, Houston, and
other writers, will furnish to the reader an idea of the practice and
performances of some of those who stood at the head of those bold
promisers: and our present newspapers daily supply us wiih a
number of the lesser dealers in specific medicines, and new-in-
vented bandages, by which the poor and eredulous are gulled out
A TREATISE ON RUPTURES. 389
of what little money they can spare. Operative quackery is not
indeed so frequent, or so readily submitted to; but I wish I could
say that not more than one life has been destroyed in our own time,
by attempts to form and support the character of an operator in
this disease: to this kind of hazard indeed the poor are luckily
not so liable, as it can only be worth the while of these rupture-
doctors to murder those who have before-hand been simple enough
to pay them well for it.
This is a subject in which mankind are much interested, and
on which a good deal might he said; but as an honest attempt to
save the afflicted from the hands of those who have no character
to lose, and whose only point is money, might, from one of the
profession, be misconstrued into malevolence and craft, I will not
enter into it, but shall conclude by wishing, that they who have
capacity to judge of these matters (which are as much the objects
of common sense, as any other kind of knowledge) would not
suffer themselves to be deluded by the impudent assertions of any
charlatan whatever, but determine in this, as they do in many
other things; that is, by the event. In short, if they who have so
much credulity, as to be inclined to believe and trust these lying
impostors, would only defer the payment of them till they had
completed their promises, the fallacy would soon be at an end.
*^* The foregoing Treatise on Herni© must be allowed to be
written with that lucid arrangement and perspicuity which dis-
tinguish the other productions from the pen of Mr. Pott. It is in-
deed a performance of extraordinary merit for the time in whick
it was published; but, as science is progressive, it is not to be
wondered at, if modern practitioners are enabled to discover in it
some inaccuracies. It has particularly been remarked, that, in
page 306, Mr. Pott has asserted that the external oblique muscle is
the only one which has a ring or opening in its tendinous fascia:
that " all descriptions and delineations of more openings than that
single one, on each side, are not representations of nature, but are
images of luxuriant fancy, and have no foundation in truth."
Since this was written, the opportunities of studying anatomy
590 A TREATISE ON RUPTURES.
have been much facilitated and extended, and from more accurate
examination this description has been found to be not quite cor-
rect. Among the laborious and accurate investigators of modern
times, Mr. Cooper holds a distinguished rank. To the subject of
Hernias he has paid particular attention; and, in the plates which
he has given of the parts concerned, he has plainly delineated and
demonstrated a ring formed by the fascia of the transversalis
muscle. This is certainly an important fact, which ought to be
well known and understood, as whoever proceeds to perform the
operation for an incarcerated hernia, with a confidence that the
ring of the external oblique can alone prevent the return of the
contents of the sac, may find himself much embarrassed at meet-
ing with another stricture, which undoubtedly is sometimes caused
by the internal ring.
Mr. Lawrence also has lately published an excellent practical
Treatise on Hernias, which gained the Jacksonian prize from the
Royal College of Surgeons, and in which this subject is accurately
investigated.
I must also observe on another passage, in page 362, in which
Mr. Pott has very properly deprecated the idea of tying the omen-
tum by including the whole of it in a ligature; but though this may
be productive of the mischiefs he has enumerated, surely it would
be right to secure such vessels as are likely to bleed before the
omentum is returned into the abdomen. Those vessels in some
subjects are naturally large: by disease they sometimes become
larger; and cannot, I conceive, be safely trusted without the
security of ligatures. If they are tied singly and separately, the
bad consequences which Mr. Pott has described would be avoids
ed. E.
391
THE FOLLOWING
OBSERVATIONS AND CASES
HELATITE TO
BUPTURES, 6)C.
Were written long after the preceding; and in former editions were
inserted in a different part of the fVork: but being a continua-
tion of the same subject, they appear more properly introduced in
this place.
SECT. I. .
DISEASES OF THE OMENTUM, PARTICULARLY OMENTAL HERNIiE.
The general doctrine regarding these is, that, although they
are sometimes troublesome from their weight and size, yet the
omentum being insensible, and very little, if at all necessary to
vitality, they do not call for our immediate assistance, and never
endanger the patient's life.
Thai omental ruptures are not attended with those immediately
hazardous circumstances, which necessarily accompany intestinal
ones, is a truth beyond all doubt; but that diseases of the omen-
tum are of little consequence, or that this kind of rupture is so
harmless, as never to bring ihe life of the patient into danger, and
to prove positivelv as well as eventually fatal, is a position which
is bj no means true.
IiU' stiiial ruptures are primarily and originally hazardous; and
this hazard arises as well from the structure, as from the func-
392 OBSERVATIONS ON RUPTURES.
tions of the parts concerned. The tender membranes of the in-
testines are very little able to bear any considerable degree of
inflammation; and neither digestion of the food, propulsion of the
chyle into and through the lacteals, nor expulsion of the faeces
from the large guts, (offices absolutely necessary to the very exist-
ence of the animal,) can be executed, while such stricture is made
on any part of the intestinal canal as either hinders its natural
motion, or renders its tube impervious; consequently, whenever
this happens, from whatever cause, the patient is immediately
disordered, and brought into a state of hazard.
The omentum is not indeed so liable to injury, either from its
structure, or from its office: the dislodgement of it from its natural
situation within the belly, or its engagement in a stricture, seldom
produces any immediate or very pressing symptoms; and therefore
its confinement within a hernial sac has seldom been regarded as
a matter of importance. Taken in a general sense, it certainly
is not. The displacement of a mere portion of caul from its na-
tural situation, and the detention of it in the groin or scrotum,
will not, in general, occasion any such interruption in any of the
functions of the animal, or so disorder its internal economy, as to
produce a considerable degree of pain or hazard: but whoever
from thence concludes that omental ruptures are absolutely void
of danger, will find himself much deceived. A more atlentive
observation of the disease, and of its effects, will inform him, that
very considerable mischief sometimes attends them, and that the
ill consequences of neglect or mismanagement, though perhaps
less frequent and less rapid, are not less real.
The ills which may attend omental herniae are of two kinds;
one of which is primary or original, proceeds from the part which
first formed the rupture, and is confined to it independent of any
other; the other is secondary, or an accidental consequence, flow-
ing indeed from the same original malady, but afleciing other
parts also.
The omentum is liable to inflammation, suppuration, gangrene,
mortification, and scirrhus, while in its natural situation within
the cavity of the belly; and each of these slates is oflen the real,
though most commonly unsuspected, cause of very alarming
symptoms, and not infrequently of death.
OBSERVATIONS ON RUPTURES. 393
it is not only liable to the same morbid alterations, when thrust
forth from the cavity into a hernial sac, but the neglect or mis-
management of it, when there, is productive of these and other
evils, which, for want of a proper attention, have either been to-
tally overlooked, or set to the account of other causes. Violent
or continued pressure on it has produced inflammation with all its
consequences; has brought on fever of a very bad kind, suppura-
tion, slough, and sphacelus; long confinement of it within a her-
nial sac has occasioned such other alteration in its form and tex-
ture as to render it truly a diseased body, and to produce many
inconveniences from such its morbid state; and an undue or in-
terrupted circulation through it, by means of stricture, occasions,
sometimes, such a collection of extravasated fluid in the sac, as
to render it a necessary object of a surgeon's attention; not to
mention that the dragging down a larger portion of the caul into
the scrotum, proves sometimes more than merely disagreeable, by
reason of its connexion with the abdominal viscera.
These are ills which arise from omental ruptures primarily,
and are dependent upon the nature of the disease, considered ab-
stractedly, without any view to or connexion with any other.
But there is another, which, although it may be called secondary,
or be considered as a consequence, is both frequent and ha-
zardous.
When a portion of the peritoneum, forming a hernial sac, has
been thrust quite down into the scrotum, I believe I may venture
to affirm, (notwithstanding what may have been said to the con-
trary,), that it seldom or never returns back into the abdomen
again, but becomes immediately, and wholly, connected with the
cellular membrane investing the spermatic vessels; so that who-
ever has once had such sac so protruded can never have any se-
curity against the disease called a rupture, but what is derived
from such means as may render the entrance into that bag too
small to permit any thing to pass from one cavity into the other.
Upon this principle, and on this only, stands the utility, and in-
deed the necessity, of trusses and such kinds of bandages. By
these, in infants, and in young subjects, such a coarctation or
lessening of the entrance into the sac is produced, that a firm and
permanent cure is often obtained; but in the luajority of adults,
VOL. I. 3 p
o'JL OBSERVATIONS ON RUPTURES,
antl ill all people far advanced in life, such effect is not to be ex-
pected. It does indeed happen to some few, but it is to be re-
garded as an accidental benefit; and the bandage being the only
means whereby a descent can b« prevented, it ought to be con-
stantly and uniemitllngly worn.
Whoever has a just idea of an hernial sac must be convinced,
that while a body, or substance of any kind, possesses that part of
it whicii communicates immediately with tlie belly, such passage
can never be closed: and, consequently, that the one point, in which
even the palliative cure of a rupture consists, can never be acconi-
pHshed.
A portion of omentum, although it be compressible, soft, and
slippery, will, while it remains in such passage, keep it as con-
stantly and as certainly open, as any other body whatever; and from
the very circumstances of its being soft, slippery, and compressi-
ble, will still more easily let any other body pass by it: a portion
of the intestinal canal is frequently pressed against the mouth of
this sac, and that with considerable force. The orifice being
open, and the omentum afibrding but little resistance, the said
portion is often pushed into the bag; and by this means a new, and
still more interesting and hazardous complaint, is added to the old
one.
This happens much more frequently than it is supposed to do-;
and is, in the nature of things, so probable, that no person who
has an omental rupture can, for any the shortest space of time,
be said to be secure against the descent of a portion of intestine;
and consequently is always liable to every kind and degree o-f
hazard attending an intestinal one.
CASE I.
A GENTLEMAN, about forty-thrcc years old, had, for some time,
been subject to a rupture of the omental kind, which came down
when he was in an erect posture, and went up with great ease
when he lay supine.
I reduced it, and put on him a truss, which answered the pur-
OBSERVATIONS ON RUPTURES. 395
pose very well, by keeping the rupture up all the while it was
worn: but the patient, disliking the necessary degree of pressure,
and finding very little inconvenience from his disease, (it being
merely a piece of caul,) laid aside the use of his bandage, and
suffered his rupture io take its own course.
Being obliged to take a long journey on horseback, and being
apprehensive that his complaint might, by exercise in hot weather,
prove troublesome, he had a mind to put his truss on again, not
doubting but that he could replace his rupture as easily as he had
been accustomed to do: be tried several limes, but could not ac-
complish it. He came to me; I tried, and was foiled. I repeated
the attempt again and again, but to no purpose, still being clear
that the disease consisted only of a portion of omentum, and that
not large.
From me he went to one of the advertisers; who having, for a
day or two, amused him with anointing his groin, put on him a
bandage with a large, hard bolster; which being buckled very
tight, he was permitted to begin his journey, and was told that,
long before he returned, the portion of caul would be shrunk to
nothing, and his disease thereby cured. He set out, and got about
twenty miles, when he found himself so ill, and in so much pain,
that he determined to come back to London; which he accom-
plished with great difficulty,
I found him in extreme pain all over his belly, which would
hardly bear being touched; he was incapable not only of sitting or
standing upright, but even of lying straight upon his back; he
could hardly bear the weight of the bed-clothes; and the most
gentle pressure, toward the bottomof his belly, and his groin, was
intolerable. The scrotum, and spermatic process, on the ruptured
side, were swollen, tense, and inflamed; his skin was hot and dry,
his pulse hard and frequent, and he had such a degree of restless-
ness, that, although motion was very painful to him, yet he could
not lie still for two minutes.
Notwithstanding the many opportunities which, before this
accident, I had had of knowing the true nature of his rupture, and
that I was perfectly convinced that it had always been omental
merely, yet from his acute pain, from the enlarged and inflamed
state of the process, and from the nature and rapidity of his symp»
396 OBSERVATIONS ON RUPTURIiS.
toms, I was much inclined to believe, that a portion of intestine
had some share in the present mischief; but the patient, who was
a very intelligent man, insisted on it that it had not, and that all
his present malady was caused by the pressure of the truss on the
omentum.
I took away a considerable quantity of blood, and, notwith-
standing the patient's opinion, directed a solution of the sal rupell.
in infus. sennas to be taken immediately, and a purging clyster to be
thrown up as soon as it could be got ready; for the parts were m
such a state, that, had there been more convincing marks of intes-
tinal stricture, reduction by the hand was at that time impractica-
ble, and unfit to be attempted. I saw him in about six or eight
hours. The discharge per anum had been such as to put an end
to all suspicion of stricture on any part of the intestinal tube, but his
inflammatory symptoms were not at all lessened. I took away
more blood, and would fain have put him into a semicupium, but
the dread of motion prevented him from complying with it. His
pain was excessive; and as he had now lost a very considerable
quantity of blood, and had had a very free discharge by stool, I
threw up a clyster of warm water, oil, and laudanum, and gave
him two grains of extract, thebaic, by the mouth. He passed s«
bad a night, that he was glad, early in the morning, to comply with
the use of the bathing tub, by the repeated use of which, and
taking care to keep the body open, by lenient, oily remedies, he,
at the end of four days, got to be easy.
Fomentation and poultice reduced the tumefaction in the groin
and scrotum; and when they were removed, the rupture appeared
to be nearly in the same state as before the accident, oily a little
larger.
Two years after this he died, and was opened; his rupture was
found to be merely omental, and the portion of caul which formed
it was, in its infcTior part, adherent to the hernial sac in two
places.
OBSERVATIONS ON RUPTURES. 39')
CASE II.
A YOUNG man, who worked as a journeyman with a silversmith
in Foster-lane, came to me three or four different times, on ac-
count of a rupture, which appeared to have every mark of being
merely omental.
It was large, and had, as he said, been for some years easily re-
ducible; but it was not at all so at his last visit to me. By a late
increase of size and weight, it was become very troublesome, as
well as very visible. Finding reduction impracticable, I recom-
mended to him the use of a suspensory bandage, and gave him di-
rections for his general conduct.
At the distance of about six months from his last visit, I was
sent for to St. Bartholomew's hospital in a hurry, to a person
supposed to labour under a hernia with stricture.
I found a man who was only not dead; he had a dying coun-
tenance, a faltering pulse, a constant hiccough, and cold extre-
mities.
As it did not appear to me that it was possible for me to do him
any service, I was going away, but was called back at the pa-
tient's particular request. He made himsejf known to me to be
the person I have just mentioned; and a friend who was with
him, gave me the following account: —
That a few days before, having an intention to marry, and be-
lieving that his rupture would be prejudicial to him, he had ap-
plied to somebody who had been recommended to him for relief;
that the person to whom he applied, having received from him
such gratuity as he could afford at that time, in part of payment,
had promised to cure him within a month; that he anointed him
for two or three days with an ointment, and then put on him a
very strict bandage; that he was ordered to wear this bandage
constantly, day and night; that when he had worn it three days.
not being able longer to endure the pain it caused, he took it off,
and went to his surgeon, who seemed to be surprized, and bad
him go home, apply to his groin and scrotum a poultice made of
boiled turnips and hog's-lard, and come to him again the next
398 OBSERVATIONS ON RUPTURES.
day; tliat the inflammation and swelling increasing, he was pre-
vented from fullilling the last injunction, and therefore sent for his
operator, who came to him, examined the parts, said he had got
the pox, and refused to do any thing more for him without the de-
posit of another five guineas; and that not being able to comply
with this demand, his friends had brought him to the hospital.
The scrotum had been of considerable size, but was now sub-
sided; it had been very painful, but was now easy; it was in many
places livid; and, upon handling, the fingers perceived that alarm-
ing crepitus, which infallibly denotes putrid air from gangrenous
membranes.
When I saw him in health, I was perfectly satisfied, that his
rupture was merely omental; I was as much satisfied, that his
present state wtis owing to his bandage; but nevertheless I cannot
but say, that I suspected a piece of intestine to have slipped
down, and to have occasioned this fatality by being pressed on.
I inquired into his discharge by stool, and was told, that he had
a large one within the last two days, but having often experienced
how liable people are to deception in these cases, I did not give
entire credit to the account.
That eyening he died, and next morning he was opened.
The scrotum and hernial sac were completely mortified, and
within the latter was a small quantity of a most exceedingly of-
fensive sanies, together with a large piece of sphacelated omen-
tum only. The whole intestinal tube was within the belly per-
fectly sound, and in good order; but the omentum within that
cavity had partaken considerably of the mischief done to that
part of it which was in the hernial sac. and was gangrenous
throughout.
CASE III.
I WAS desired to visit a gentleman at Hackney, who had for
some years been afflicted with a rupture, which at different times
had been examined by Mr. Sainthill, Mr. Samuel Sharpe, and
others; and had, by every body, been deemed to be merely omen-
tal. For some years it had been kept up by means of a steel
OBSERVATIONS ON KUPTURF.S. 399
truss; but, a few months before I suw bim he had laid aside his
truss, and had put on a dimity bandage, ^vilh a Large bolster,
which he had worn very tig'ally buckled. How he had managed
himself in other respccls, I know not; but I found him with
his groin and scrotum much swollen, and very painful to the
touch; he was hot and feverish, and had been two days without a
stool. The state of the parts was such, that an immediate attempt
to reduce the rupture by the hand was impracticable, at least
could not have been aitended with any probability of success. He
was immediately let blood, had a clyster, and an aperient draught.
Next day 1 found him worse, in more pain, with more inflamma-
tion, and a greater degree of tumefaction, and had not yet had a
stool. I was obliged to depend on the patient's own account of
his case previous to this attack. He insisted on it, that his rup-
ture had neve;r been intestinal, and that every body who had seen
it had given him that assurance. This I could not contradict,
but was, at the same time, much inclined to believe, that a por-
tion of intestine was down now. The cataplasm was applied
over the whole scrotum and groin, a stimulating clyster again
thrown up, and a purging mixture ordered to be taken, cochleatim,
every tWo hours, until he should have stools, but all to no pur-
pose.
On the third day he was worse in every respect; his belly ex-
ceedingly tense, his pain great, his restlessness fatiguing, arid he
felt not the least tendency towards a discharge per anum.
I proposed the operation, but the patient and his friends ob-
jected. A clyster, of an infusion of tobacco, was administered.
This produced such sickness and languor, with cold sweats, &c. as
alarmed every body, but produced no stool.
Late in the evening, he submitted to the operation. The parts
were now so altered, that I guarded myself with a most doubt-
ful prognostic. I made an incision from the groin to the bottom
of the scrotum: the skin, dartos, and hernial sac, were all gan-
grenous; and from the cavity of the sac I let out a considerable
quantity of a most offensive sanies, and with it a large, putrid
slough, which appeared to have been a part of the omentum. I
examined the opening in the abdominal muscle, and was satisfied
that it was in a natural state, and (hat nothing from the abdomen
400 OBSERVATIONS ON RUPTURES.
was engaged in it. On which account, I did not meddle with it,
but having dressed the wound superficially, put on his poultice
again. Dr. de la Cour was present at the operation, and directed
for the patient. Another day passed without stool, and this I
thought must have been his last day; but on the fifth he had a
most plentiful discharge, and was thereby relieved from the ten-
sion of his belly, and his most troublesome symptoms.
The sore was a long time crude and unkindly, but by means of
the bark, and proper diet, all difficulties were surmounted, and
the patient got well.
Had a piece of intestine been in the sac, it must, I think, have
necessarily partaken of the state in which both it and the omen-
tum were; and although the patient might possibly have survived,
yet a discharge of fsBces through the wound must, at least for a
time, have been the consequence; but here was nothing of that
kind, nor any reason, after the constipation was removed, to sup-
pose that the intestine had ever sustained any injury, or had any
share in the complaint.
CASE IV.
A BiAN, about fifty-five years old, asked my opinion concerning
a hard swelling, which he had on each side, both in the groin and
scrotum. ''
To the eye they appeared like omental hernias; but upon ex-
amination, they were not only unequal in their surface, but craggy„
and incompressibly hard.
The patient said, that at the time of handling them they gave
him very little uneasiness, but that such handling always made
ihem painful for some time after: that he was, at times, attacked
with acute pain darting through his belly, up into his loins; and
that such attack was frequently attended with a nausea, and an
Inclination to vomit; that he had been subject to a painful colic,
attended generally with constipation of belly; that an erect pos-
ture, if continued for any length of time, was very irksome; that
these swellings were for several years soft, and easily returnable
into the belly; that while they were so, he had, by the advice of
OBSERVATIONS ON RUPTURES. ' 401
Mr. Samuel Sharpe, worn a steel truss; but that being engaged iu
a bustling active kind of life, and the truss not always doing its
duty, he had left it off for some years. That for the last two
years he had never been able to return either of them, since which
they had altered very much; that in their present state he had
consulted several of the profession, and some quacks; that by some
they had been deemed scirrhous testicles; by others, scirrhi of the
spermatic processes; that he had gone through a course of mer-
curial inunction; had taken freely of the solution of sublimate cu.
de coot. rad. sarsaparillae, and had (in his own phrase) swallowed
a wheel-barrow-full of cicuta; that he had been promised a cure
by having them laid open, to which he had submitted, had not the
operator been too lavish in his promises, and too exorbitant in his
demands; and that frequent attempts had been made to soften
them by fomentation, poultice, &c. but all to no purpose.
He had a sallow complexion, a languid fatigued look, a weak
irregular pulse, too much heat and thirst, and too little urine: upon
the whole, he seemed a very improper subject for any chirurgic
treatment, if any could have been rationally proposed; but as it
did not appear to me that any thing of that kind could be done for
him, I advised him to keep his scrotum suspended, and to consult
a physician on account of his general slate.
Not long after, his legs swelled, he lost his appetite, and his
urinary secretion almost totally ceased. The consequence of
which was, a general anasarca, and death.
In each groin, and on each side in the scrotum, was a hernial
sac, bearing all the marks of antiquity: in eajch of these was a
hard, knotty, irregular kind of body, whose surface was covered
with varicous vessels.
These bodies passed from the cavity of the belly, through the
opening in the abdominal muscle, were continuations from tlse
omentum, and were truly cancerous.
CASE V.
That the residence of a portion of omentum in an open hernial
sac, must render the patient constantly liable to the descent ©f a
VOL. I. .S E
402 OBSERVATIONS ON RUPTURES,
portion of" intestine, is .so self-evident, that it cannot admit the'
smallest doubt; but the following case being rather remarkable I
have inserted it.
A drunken idle fellow, who lived in the neighbourhood of St.
BarthoJome^v''s, used to come frequently to the surgery for pled-
gets for broken heads, &c. He had also a small omental hernia,
as fairly and decisively characterised as possible. Myself, and
all the surgeons, had at different limes replaced it for him, and the
hospital hadionce or twice given him a truss; but, being much
oftencr drnnk than sober, he seldom wore it at all, and when he
did, it was scldnm in the right place.
One day while i was at the hospital, he was brought in with an
immense swelling of the scrotum, and all the symptoms of a her-
nia with stric'ure, and those so far advanced, that he had no
chance but from the operation, which I therefore performed im-
mediately.
In the sac was a considerable* portion of the ileum, and a large
piece of the colon, with the appendicula vermiformis, together
with the small piece of omentum, which had constituted the ori-
ginal rupture. The parts were mortified, and the man died.
Unless it can be supposed, that so large a quantity of intestine
could, by every body, be mistaken for a small one of omentum
only, it must be clear that the residence of that small piece of
omentum, gave the opportunity for the formation of the intestinal
hernia, and cost the poor man his life; more especially if it be
noted, that the increase of tumefaction and attack of bad symp-
toms were the immediate consequence of an exertion of strength.
CASE VI.
While I was correcting these papers for the press, I was de-
sired to go down to St. Katharine's to see a patient, who was sup-
posed to be afflicted with an incarcerated hernia.
I found a man between sixty and seventy, whose scrotum was
large and full, and, as I thought, contained both omentum and in-
testine.
Tt was the third day since he had had a stool, although gentle
OBSERVATIONS ON RUPTURE$> 403
cathartics had been given eacli day. His pulse waft rather full,
but otherwise not much amiss; he had now and then an inclina-
tion to vomit, and his belly was very tense; but, on the other hand,
he had neither the sensation of general or local pain, either upon
being examined, or put into motion, which persons labouring under
a stricture most commonly have; neither had the spermatic pro-
cess the feel which it usually has in such cases.
I could not say that I thought him in immediate hazard, al-
though the irreducibility of his rupture, and the length of time
which bad passed since he had a stool, were certainly unfavour-
able circumstances. I directed a tobacco clyster to be given im-
mediately, and five grains of extractum calharticum to be taken,
alternis horis, until he should have a stool. The clyster was ad-
ministered and repeated, and the pills were taken, and I visited
the patient early the next morning.
He had not had any discharge per anum, his belly was become
much more tense, and I thought him upon the whole so much
worse, that I proposed the operation, and the patient submitted
to it.
In the hernial sac was a large piece of omentum, or rather of
what had been omentum, but which was now hardened into a
large flat cake, as incompressible as cold bees'-wax, and about the
size of a large mangoe: it distended all the upper part of the sac,
and was adherent to the lower part of it. Behind this large body
lay a portion of the intestinum ileum; and, below this, that part of
the colon which is annexed to it; the colon was considerably dis-
tended with flatus; and the ileum was so wedged in and pressed,
by the altered omentum, that nothing could possibly pass through
it. When the portion of omentum was removed, the tendon made
so little stricture on the gut, that, had it not been for the great dis-
tention of the colon, it might have been returned into the belly
without division.
In short the constipation of belly, and mischief proceeding from
thence, seemed to arise entirely from compression made by the
hardened omentum, and not from a stricture.
404 OBSERVATIONS ON RUPTURES.
In my general treatise on ruptures, I have ventured to dlssenfc
from the commonly received doctrine concerning the propriety of
tying the omentum previous to its extirpation, when it may be
found necessary to remove a part of it; and have said, that I
thought it not only unnecessary, but pernicious.
Perhaps I may have conceived an unreasonable prejudice
against this practice, and it maj not appear to others so ha-
zardous, or so improper, as it does to me; perhaps the cases which
follow, and which are some of those that have furnished me with
my objections, may not be thought cases in point; and the mis-
carriages in them may be thought to be deducible from other
causes: all I can say is, that it appeared to me, that the patients
suffered principally, if not merely, from this cause; and that as I
am by repeated experience convinced, that a portion of the omen-
tum, however large, may be extirpated with perfect safely, with-
out being previously tied, I shall never practise or advise the
ligaiare.
CASE VIl,
A MAN, about thirty years old, was taken into St. Bartholo-
mew's hospital for a considerable swelling of the groin or scrotum.
The account he gave of himself was as follows: that he had for
several years a rupture, which many surgeons, who had seen it,
had deemed to be merely omental; that he had formerly had a
truss, but whether from its being ill made, or from his injudicious
manner of wearing it, it had never kept his rupture properly up,
and he had long disused it; and that the day before he was brought
into the hospital, a horse had kicked him in the groin, and brought
on that increase of pain and swelling of which he now com-
plained.
It was Mr. Nourse's week for accidents, and he consequently
took the care of him. He was let blood, had a clyster, and a
poultice was applied.
The next day the swelling was the same, and the man had not
OBSERVATIONS ON RUPTURES. 406
Jiad any stool. A purge was administered, which he ejected by
vonfiil; and another clyster was injected in the evening. On the
third day, finding that nothing had passed, Mr. Nourse suspected
that the intestine was concerned: he bled the man again largely,
and ordered two spoonfuls of a purging mixture to be given every
two hours,' until he should have stools. That evening he vomited
two or three times; and next morning, Toeing still without a stool,
Mr. Nourse determined upon the operation.
The hernial sac was sound, thick, and tough, and contained a
portion of omentum, and some bloody water. Mr. Nourse and
myself both examined the omentum carefully, upon a supposition
that we should find some intestine within it. It was perfectly
sound, but its vessels were considerably dilated: there was no in-
testine, nor did the tendon bind upon the omentum. As there
was no gut down, and as the portion of caul v/as now too large
to repass the ring, Mr. Nourse made a strict ligature on it, just
On this side, and cut it off.
Soon after the operation, the man had stools; but during that
night got little or no sleep, and complained of much pain. The
next day he was worse, was feverish, complained of great pain
about his navel, and that he could not sit or stand upright, but
had two loose stools.
On the third day he was still worse; that is, had more fever,
complained that his pain in his belly was excessive, and could
keep nothing on his stomach. On the fourth day, toward even-
ing, his pain suddenly left him, and early in the morning he died.
Mr. Nourse, who was still apprehensive that the intestinal ca-
nal was some way or other concerned in the mischief, desired
me to open the body.
The abdominal tendon was sound and unhurt, nor was there
any such appearance about the wound as always accompanies
mischief proceeding from thence: the intestiries were perfectly
free from blemish, inflammation, or obstruction, nor was there
any appearance of disease of any kind on or about any of the vis-
cera, except the omentum, w^hich was gangrenous through its
whole extent.
What share the inflammation of the omentum might have in
prefienting a free passage through the intestines I know not, nor
406 OBSERVATIONS ON RUPTURES.
to what other cause such obstruction might possibly be owing;
but that the omentum was sound, at the time of the operation,
and gangrenous when the patient died, is beyond all doubt.
CASE VIIL
A MAN, about forty years old, who had for several years been
afflicted with a rupture which had always been deemed to be
merely omental, was brought into St. Bartholoinew's hospital la-
bouring under all the symptoms of an intestinal hernia, with stric-
ture; and those so pressing, that the operation immediately per-
formed was his only chance.
Upon dividing the sac, a large piece of omentum (which was
considerably thickened in its texture, and whose vessels were con-
siderably distended) presented itself. This was carefully ex-
panded, as far as it would admit, and laid first on one side, and
then on the other, but no other body discovered. The incision
being continued higher up, in order to get at the ring, as it is call-
ed, a poriion of intestine was discovered; it was so small, as hard-
ly to consist of the whole diameter of the gut, but begirt very
tightly. I had, when the intestine was fairly in view, a mind to
try whether 1 could not return it without dividing the tendon,
and succeeded in the attempt. When this was done, the consi-
deration was, what to do with the omentum. It was so large,
and so affected by stricture, that it could not repass the abdomi-
nal tendon without division: as the gut was returned, it seemed a
pity to divide the tendon merely on account of the caul: it was
therefore determined to tie it, and cut it off.
The man had a plentiful stool in an hour after the operation,
but toward evening, and during the night, was much out of order.
Next morning he was hot and restless, had a frequent and full
pulse, complained of great pain about his navel, and all over his
belly, which was much too tense, and he was now and then
very sick.
Blood was drawn from him freely; he had an oily laxative
clyster; and Dr. Pitcairn directed for him. On the third day, all
OBSERVATIOWS ON RUPTURES. 40'i
his febrile symptoms, and his pain, were much exaspcraicd, not-
withstanding he had three or four stools.
I think I may venture to say, that both the physician and myself
did every thing in our power for him; but on the fourlli evening
he died.
As the case had given me some concern, upon a supposition that
the man might have had a better chance, had the tendon been
divided for the return of the gut, I opened him as soon as I had
notice of his death, I examined the whole intestinal canal, and
found it free from blemish: the peritoneum was una.l(ered; but all
that was left of the omentum was gangrenous.
CASE IX.
A MAN, about thirty-six years old, was a patient in St. Bariho-
lomew's for a sore leg. While he was there, he desired me to
look at a rupture, which he had long had, and which was clearly
omental and irreducible.
When his leg was well, he desired me to cut him, as he called
it; alleging, that his rupture was so troublesome, that it prevented
him from following his business. I refused it, and directed him to
wear a suspensory bag.
He solicited me again and again, and at last, overcome by his
importunity, I performed the operation. The sac was thin, and
the piece of omentum not large, nor at all altered, nor was there
any thing else in the bag: I made a ligature, and cut it off with-
out meddling with the tendon. From the time of the operation he
was in constant pain all over his belly.
Bleeding, laxative medicines, clysters, &c. were administered,
but to no purpose. On the fourth day he died, and had no
appearance of mischief about him, except a highly inflamed
omentum.
INTESTINAL HERNIiE.
When a portion of intestine, which has passed out from the
cavity of the abdomen through the opening in the oblique muscle,.
408 OBSfcRVATIOlNS ON RirPTURES.
is so begirt as not to be capable of executing its jjioper office,
the person, to whom this happens, may be said to be in immediate
danger.
The general offices of the intestinal tube are, digestion of the
food, formation of chyle, impulsion of it into the lacteals, and ex-
pulsion of the faeces forth from the body. If these so necessary
functions are, for any considerable time, suspended or prevented,
the consequence is too obvious to need mentioning: fortunately for
mankind, this cannot happen unknown to us. Whenever such
stricture is made, symptoms and complaints arjse which warn us
of our danger: pain, tumefaction, and incapacity of going lo stool,
are the first and most immediate effects. If the case be neglected,
or no proper remedy used, inflammation, fever, sickness, and
vomiling, soon follow; and these are often, in a short space of
time, succeeded by hiccough, gangrene, and mortification. Who-
ever considers what the first of these are indications of, and knows
what will inevitably be the consequence if they be not obviated,
must be sensible, that the very slightest attack of this kind ought
to put us on our guard, and excite us to use our utmost endeavours
to prevent further mischief. How long the first and seemingly
slightest symptoms may continue before material injury be done,
no man can pretend to say: this must depend upon a variety of
circumstances, and will be different in different cases; but as no
man can be duly and intimately acquainted with these circum-
stances, and as the change from the most slight to the most
hazardous is sometimes very rapid, no one can be vindicated in
suffering the smallest portion of time to be lost by waiting a few
hours.
Tlie first thing to be done is to attempt the reduction of the in-
testine: if this fails, our next endeavour must be to relieve the
symptoms, and thereby remove the obstruction to such reduction.
The means prescribed for this purpose are, phlebotomy, clysters,
cathartics, a semicupiura or warm bath, fomentation, embroca-
tion, and cataplasm; and these, by the generality of our writers
of systems and institutes, are ordered indiscriminately, as if their
efficacy were nearly equal, and it was a matter of indifference
which a practitioner made use of. This I cannot conceive to be
true: some of them are really useful; but others, as far as my
OBSERVATIONS ON RUPTURES. 409
experience goes, of little or no use at all. Among the former, I
reckon phlebotomy, cathartic medicines, clysters, and the vvarm
bath; among the latter, embrocation, fomentation, and poultice.
The former have saved many a life: from the latter, I never saw
any material benefit, though I have often and often tried them;
and I am much inclined (o believe, that the use of them has cost
many a person dear, by occasioning a loss of that time which
ought to have been otherwise employed. The inflammation and
distention of the intestine can never be removed while it is begirt
by the tendon of the abdominal muscle; whatever may be the
original cause of the stricture, the effect must be the same; the
tendon lies out of the reach or induence of a greasy poultice; the
external skin may indeed be relaxed by it, and some small part of
the uneasiness may thereby be relieved; but this is of no impor-
tance toward appeasing the symptoms, lessening the hazard, or
affording a remedy for the original evil. The mere relaxation of
the skin will not affect the stricture made by the tendon, the
warmth of the poultice will increase the distention, and the in-
testine will become gangrenous, notwithstanding a small part of
the external inflammation may seem to be appeased.*
If the symptoms are neither such, nor so pressing, as to require
the chirurgic operation; or if the fears and apprehensions of the
patient, or of friends, prevent such operation, however necessary
it may be, the most powerful and most efficacious means of obtaining
relief are, phlebotomy, warm water, and the exhibition of such
medicines as are likely to produce stools: by the first we reduce
the strength of the patient, lessen the velocity of the circulating
fluids, moderate the febrile heat, and take the chance of a deli-
quium; by the second we endeavour to relax the tendinous open-
ing by which the intestine is begirt; and by the third, the discharge
of faeces, through the intestinal canal, is attempted. The power
of the two first is clear and undoubted; but I cannot help thinking,
that we are, in some degree, wrong about the last. Cathartic
' Cold, discutieiit applications bid much fairer to retard the hasty pro-
gress of the inflamraation, than warm ones ; and will be found to answer the
purpose much better. Such as solutions of sal ammoniac. Cfud, in vinegar,
the sp. mindereri, the acet, l3'tliar!*irit. and such like.
VOL. r. OF
410 OBSERVATfONS ON RUPTURES.
medicines have, in all times, been prescribed in the case of hernia
with slrictiire; but the true intention, whicli ought hy their means
to be aimed at, does not seem to have been, in general, clearly
understood: this perhaps is the reason why pracliuoners and
writers disagree so much about the kind of medicines which they
think most proper; some advising those which are of the lenient
unirritating kind, others prescribing those which are most stimu-
lating: both cannot be right, and therefore it may be worth while
to inquire, what should be the point aimed at, and which are the
most likely means to accomplish such end.
Is a discharge, per anum, the primary view, and therefore the
first object of attention? or is such discharge to be regarded only
as a necessary or natural consequence of the removal of the intes-
tine from its prison.'' If the former be the case, it is clear, that in
the circumstances in which such patient must be, stools cannot be
procured too soon, or by means which are too easy; and that such
medicines as are most likely to slip through without stimulus, or
irritation, must be the most proper, and most likely, to answer the
end; but if the case be otherwise, if the first view should be to
extricate the gut from its stricture, and the discharge of faeces is
to be regarded only as a necessary consequence of such removal,
then, 1 think, it is as clear, that such lenients are unfit, because
unequal to the task; and that a power or faculty of stimulating or
irritating the muscular coat of the intestinal canal, ought to be
the property of whatever is administered.
That a depletion of that canal is a great and immediate relief
to the patient, by unloading the belly, and lessening the tension,
is beyond a doubt; and it is as true, that, without such discharge,
the patient must perish, even though the stricture be taken off;
but still the two objects are distinct and different, and the re-
movaLor extrication of the imprisoned piece is clearly the first."*
n* It may not improperly, in this place, be asked, whether the operation of
a purging medicine may not be different from either of these? and wliether
it may not be in an incarcerated hernia wliat it sometimes is in an ileus, where
it often seems to act by overpowering that spasm which had begun to excite
inflammation, and would soon bring on mortification? What still adds force
to .this method of reasoning is, the consideration of the great relief always
obtained from a warm bath, ^Yhethe^ this be generally true or not, it is
OBSERVATIONS ON RUPTURES. 411
When purgative medicines of any kind are given by the mouth,
in the case of a strangulated hernia, and do not succeed in remov-
ing the intestine from the stricture, they are either rejected by
vomii, or, by deriving an increased quantity of acrimonious faecal
matter downward, add to the pain and tension of the belly.
This is a very material objection to the use of all cathartics
given by the mouth, and more especially to those whose bulk or
quantity is at all large; and renders the application of such kind
of medicines to that part of the intestinal canal which is below
the stricture much preferable.
Indeed, the superior advantages of stimulating medicines, given
per anum, are, in this case, many and great: they give much less
disturbance to the stomach, they occasion no pain in the belly, nor
do they at all increase the load or tension; they may be repeated
frequently; and, what is of the most consequence, they may con-
sist of such materials as cannot properly, or indeed safely, be given
by the mouth. All these are manifest advantages; but the last
circumstance is peculiarly so, for the tobacco-smoke cannot pos-
sibly be swalloiVed, nor would any man in his senses think of
putting the infusion into the stomach, although it is well known,
not only that both may be very safely administered in the form of
clyster, but that they are the most powerfully efficacious and the
most useful medicines we are acquainted with for such purpose.
I have mentioned the smoke and the infusion of tobacco as
being equally useful, and have, from repealed experience, found
them so.
Where a proper machine is at hand, or can easily be procured,
I should certainly prefer the smoke to the infusion; because, the
effects which both are apt to produce on the nervous system of
the patient are, I think, lighter in the former than in the latter;
but where such machine has not been at hand, nor could be pro-
cured without a loss of time, which, in these cases, is always pre-
cious, I have frequently used the infusion, and generally very suc-
cessfully. The symptoms arising from the intoxicating quality
certainly well worth consideration. May not from this also be inferred the
reason why opium, joined with purgatives, is sometimes, in the same disease,
found to render the operation of the latter more successful?
412 OBSERVATIONS ON RUPTURES, •
of the tobacco, the languor, the cold sweat, &c. which this weed
causes, more esjieiialiy in those who have not been accustomed to
it, are, as I have said, I think, rather more from the infusion than
from the smoke; but, though I have often used it. I do not remem-
ber ever to have seen any ill eflect from it. It generally makes
the patient very sick," and produces a fainting and a cold sweat,
ivhich, to those who do not immediately reflect on the intoxicating
quality of tobacco, and the symptoms of such intoxication, may
appear alarming; but, whether ii be from the swooning, or from
the irritation made in the intestinal canal, or, which is much more
likely, from both conjointly, I have, several times, seen ruptures,
which have resisted all attempts by the hand, return, of them-
selves, untouched, during the influence of such clyster.
Many other stimulating applications to the rtctum I have, at
different times, made trial of, but never found any at all equal, in
effect, to the tobacco; nor did I ever see any of them produce that
convulsive motion of the muscles of the abdomen, which most
frequently accompanies the sickness attending the use of this
weed, and which, although fatiguing and troublesome while it
lasts, yet is certainly one of the means whereby the extrication of
the portion of intestine is accomplished.
I have also several times seen them both fail, after fair and re-
peated trial. Whoever expects infallibility in medicine will be
disappointed; but I can, with truth, affirm, that I have seen both
the smoke and the infusion succeed much oftener than any thing
else, arfd sometimes in very desperate cases.
CASE X.
I vvls desired to visit a ruptured patient with Mr. James, then
surgeon to St. Luke's hospital.
The patient was a stout, healthy man, about thirty; the rupture
was large, hard, painful, and beginning to be inflamed on the out-
side; no stool had passed for two days; the man had great pain all
" The infusion, which 1 have always used, has been made by pouring one
pint of boiling water on one drachm of tobacco.
OBSERVATIONS ON RUPTURES. 413
over his belly, and a frequent vomiting. Mr. James had many
times (ried to reduce it; he had bled him freely; and had given
both purges and clysters, but all without eflect.
The scrotum was exceedingly tense, and the pain which at-
tended the most gentle handling was so exquisite, as not only to
render all attempts for reduction, by the hand, improper, but ha-
zardous.
Ii was about noon when I saw the man: every thing except the
tobacco had been tried; the symptoms were advancing hastily, and
the operation was proposed and submitted to; but, while our
things were getting ready, we thought we might as well try the
smoke clyster.
One ounce of tobacco was expended without any effect at all,
either general or local; but, toward the consumption of another,
the patient became sick and faint, and complained of a strange
kind of motion in his belly, and also in his rupture. Upon turn-
ing the bed-clothes back, the motion was not only to be felt within
th< scrotum, but was even visible; this motion continued about two
minutes, when the intestine, without being touched, returned; the
man became immediately easy; and, in half an hour, had a plenti-
ful discharge per anum.
CASE XL
In the month of September, 1767, I was sent for in a hurry to
some little distance from London, in order to perform the opera-
tion for the bubonocele.
I found a very large rupture on the right side, and that in so
painful a state, as not to permit the most gentle handling. The
patient had been treated with the greatest propriety, had been
freely and repeatedly let blood, had taken purging medicines,
clysters, &c. and had been several times in a bathing tub: his
vomiting was frequent, he had a tendency to a hiccough, and he
could not bear to extend, in the smallest degree, the thigh on the
ruptured side.
The operation had been consented to before I had been sent for;
but, upon my asking the gentleman who attended, if he had a ma-
414 OBSERVATIONS ON RUPTURES.
chine for giving the tobacco-smoke clyster, and being answered in
the affirmative, we determined to try it first.
When about half an hour had been spent in the continual im-
pulsion of the smoke, the man cried out, ' My rupture is going
up!' and, in the space of two or three minutes, it did so, with a
noise which was heard by every one in the room.
CASE XII.
A GENTLEMAN, whom I had long known, had often showed me
a rupture, which he had laboured under as long as he could re-
member, and which was now and then troublesome to him, be-
cause he could not wear a truss to keep it within the abdomen.
It was of the congenial kind; that is, the sac of the hernia was
formed by what should have been the tunica vaginalis testis. But
his testicle, on that side, had never descended from the groin, but
lay just on the outside of the abdominal opening; neither had the
portion of intestine got any lower, so that both of them lay to-
gether: on which account, he not only never could wear a truss,
but even the waistband of his breeches, if buttoned tight, was trou-
blesome.
This gentleman was suddenly seized with the symptoms of a
stricture, and those not slight, even at the first attack. The piece
of intestine, though always in the groin when he was in an erect
posture, had always gone up upon his going to bed, and was al-
ways returnable when he was supine. He tried now to reduce
it as usual. He sent for me, and all my attempts were equally
successless. His belly was very hard, he began to vomit, and the
testicle became very painful to the touch.
All the circumstances were disagreeable, the symptoms ad-
vanced wiih uncommon rapidity, the portion of gut was small, the
testicle inflamed and somewhat enlarged: an operation might
become necessary, but could not, in such circumstances, be de-
sirable.
He was bled freely, even to swooning; purging medicines were
given, and immediaiely rejected; clysters had no eifect, but were
OBSERVATIONS ON RUPTURES. 416
as immediately returned; and the patient, knowing his own situa-
tion, was much alarmed.
Dr. de la Cour, who was his physician, was called in, and
having tried the tobacco- smoke ineffectually, we agreed to throw
up a pint of the infusion, made as before related. It soon made
him exceedingly sick and faint, and caused a large discharge of
wind, upward and downward, from which I expected a return of
the gut, but in vain. At the distance of an hour, or two, the in-
fusion was repeated, with the same effect of faintness and sick-
ness, during which he was put into warm water; and when he
had been in it a few minutes, the slightest application of the hand
obtained immediate reduction, and stools.
CASE XIII.
The late Mr. Fullager desired me to go with him to see a
wine-merchant in Billiter-lane, who had all the symptoms of
strangulation in the case of a scrotal hernia, and whose rupture
he had ineffectually endeavoured to reduce. I tried, and was
also foiled. The symptoms were rather pressing. Mr. Smith,
in Cheapside, who had been the apothecary to Mr, James's patient,
was also apothecary here. It was determined that I should meet
Mr. Fullager again, in about three hours, in order to perform the
operation; and that, in the mean time, Mr. Smith should throw
up the tobacco-smoke. At the appointed time we met, and
found Mr. Smith employed as we had desired; I laid my hand on
the rupture to examine the state of it, and it was wonderful with
what facility it went up.
The same thing, exactly, happened to me with a coachman of
the late Dr. Nicol of the Charter-house: but the same man, upon a
return of the complaint, at about two years distance, was not
again so fortunate; the smoke and infusion both failed, and the
operation was performed; but too late.
It is as yet, with many, a disputed point, in the case of incarcer-
ation of. a portion of intestine in a hernia, whether the stricture
made by the tendon be original or consequential; or, in other
41t> OBSERVATIONS ON RUPTURES.
words, wlietlier (he disease be not ftriginally in the intestine, and
the stricture a mere effect of its dislodgemenl and distention.
The arguments used in support of the latter opinion are bv no means
void of force, but at the same time I cannot think them conclu-
sive. The perfect health and ease of many, nay of every body,
immediately before a sudden descent, the very pressing and alarm-
ing symptoms with which such descent is often attended almost
instantaneously, and the relief which reduction immediately pro-
duces in the majority of such cases, together with the immediate
and total removal or dissipation of all the evils occasioned by the
confinement, seem to prove the general opinion (o be true.
On the other hand, the perfectly quiet, easy, and uncompressed
state of the parts, in many instances, immediately previous to the
invasion of bad symptoms, in cases where there has been no
exertion of strength, nor any apparent accession of a larger and
new portion of gut, are circumstances which, added (o the inca-
pacity of the tendon to contract, are well worth weighing, as they
certainly give force to the former supposition.
As a mere point of speculation, it is not perhaps a matter of
very great importance; but when considered as applied to prac-
tice, and influencing our conduct with regard to the chirurgic
operation, it becomes very interesting indeed.
When the hand and the common means for reduction fail, the
operation is our only resource, and if applied to in time, very sel-
dom fails; so seldom, that I believe I might venture to say, not
one in fifty" dies of it, if timely and judiciously executed; and
when it becomes absolutely necessary, it is the unicum remedium.
This consideration renders it a matter of still more importance;
for as in cases where it becomes necessary and our only hope, it
ought always to be proposed; for the same reasons, in cases where
it is not necessary, it ought not to be thought of; and where it
cannot be of use, it ought not to be done.
The intestinal tube, whether within the belly in its natural si-
tuation, or thrust forth from it in the form of hernia, is liable to
diseases whose symptoms are peculiar to itself. Where there is
no hernia, nobody doubts concerning the nature of the case; but
" T mean of tlie operation consklerecl abstractedly.
OBSERVATIONS ON RUPTURES. 417
where there is one, from the simiiarily of the symptoms, it always
takes the blame; offen deservedly, sometimes much the contrary.
In the case of old, unrechiced hernias, there is no reason why
the portion of intestine, forming such complaint, should be exempt
from such distempers as the canal is liable to: on the contrary, it
is reasonable to suppose, that by such unnatural situation and con-
finement, it would become rather more liable. But be this as it
may, certain it is, that inflammation of the intestine, violent dis-
tention of it, with loss of peristaltic motion, and stoppage of stools,
is sooielimes the case in a hernia where the abdominal tendon has
no share in the mischief; and as certain it is, that in such case the
operator can do no good. In some instances this mav, by atten-
tive inquisition, be learned, and the operation thereby preserved
from a disgrace: in others, it can only be known by its proving
unsuccessful.
When the disease is the mere consequence of stricture, and the
gut, previous to such stricture, was free from distemper, it seldom,
I might almost venture to say never, happens: but that the setting
it free is followed by a discharge peranum, especially if such in-
tention be properly assisted. But when the disease was originally
in the intestine, and the intestine either not bound by any stric-
ture, or a stricture the mere consequence of the previous distemper
of the gut, it most frequently happens that such discharge does not
follow the operation^ nor is obtainable by any means after it. This
I have always regarded as a characferistic mark of the true nature
of the malady; to which I think, from what I have seen of those
cases, I might add another, which is the great difficulty, and, in
some cases, impossibility of keeping the reduced intestine (after
the operation) within the belly — a circumstance which I have
seen sometimes to be absolutely imj)ossible. In the cases where
all the mischief arises from the mere prolapsus and stricture, the
returned intestine becomes immediately pervious, and enjoying its
peristaltic motion, keeps its place, and does its office; but where,
by previous distemper, it is rendered impervious, and deprived of
its motion, it cannot execute its office, it remains violently dis-
tended, and is, with great difficulty, kept within the belly, of
Avhich I could give many instances. This is, on several accounts,
a matter of importance, both to patient andsuraeon: with regard
VOL,. I, 3 G
■il8 OBSERVATIONS ON RUPTURES.
1o the ibrmer, it is not merely the alarm, anxiety, horror, and
pain, which necessarily attend an operation of such kind, and of
such serious consequence, and which, of themselves, are surely
enough: but the distemper not residing in, nor being produced by
the stricture, the necessary symptomatic fever attending such an
operation must, in the nature of things, be a circumstance of ad-
ditional hazard: and with regard to the surgeon, the difficulty of
returning the distended intestine, and of keeping it in the belly
after it has been returned, together with tlie most frequent, and
indeed most probable, event iS such case, render it very unplea-
sant, and what every man would choose to avoid. No man can
command success; but every man would wish to be in the vvav
of it.
CONGENIAL HERNLE.
The diiference between these and other ruptures, is not a matter
of mere anatomical speculation: there are in the former several
particularities which require a practitioner's very serious attention,
and which an operator ought always to be aware of.
The sac of a common hernia, every one knows, is formed by
the protrusion of the peritoneum, through the natural opening in
the tendon of the external, oblique muscle of the abdomen. This
sac, at first, extends no further than the sroin, but is, by means ot
its contents, gradually pushed low^er and Tower until it gets into
the scrotum. It always lies anterior to ihe spermatic vessels, and
is enveloped in the cellular membrane, which makes the tunica
communis of the said vessels, forms a cavity perfectly distinct
from the tunica vaginalis testis, and never does or can contain the
testicle within it.
In the congenial hernia, the case is different: in this, the sac
is not formed by the unnatural protrusion of a portion of the
peritoneum, which ought to have remained within the belly, but
is made by the unclosed vaginal coat of the testicle; consequently
the said sac, constantly and necessarily, contains within it the
testicle, together with whatever else may have passed from the
abdomen to constitute the hernia, and which parts must therefore
be in contact with the testicle.
OBSERVATIONS ON RUPTURES. -^IS
From this particularity result some circumstances very ne-
cessary for a practitioner to be acquainted witb. Such are the
following: —
1. It sometimes happens, that, in infants, a portion of intestine
slips down along with the testicle, prevents the closing of the tunica
vaginalis, and thereby constitutes the disease.
3. It sometimes happens, that a portion of gut only comes down,
the testicle never passing forth from the abdomen, or remaining in
the groin, and falling no lower.
3. In this species of hernia a stricture, or strictures, are some-
times met with, which are formed merely by the contraction or
coarctation of the neck of the vaginal coat or sac, independent of
the abdominal tendon. And,
4. The parts contained in a common hernia are liable to con-
tract cohesions with each other, or wilh the sac; but in the con-
genial both omentum and gut are liable to become connected with
the testicle; which connexion will, sometimes, demand all the
judgment and all the dexterity of an operator. So that, nice and
delicate as the operation of a bubonocele is in the most simple
and common case, it becomes much more so in the congenial
rupture.
CASE XIV.
A BOY, about fourteen years old, was taken into St. Bartho-
lomew's hospital for a strumous, lumbal abscess, the matter of
which had made its way out in the upper part of the thigh. The
discharge was great, and the boy sinking apace.
While he lived I took notice of a particular appearance on one
side of the scrotum.
The spermatic process, at its exit from the belly, was large and
full, and plainly contained something which should not be there;
immediately below the fulness, the process was of little more than
its natural size; but just above the testicle, it was again consider-
ably enlarged, and had the same feel as above.
The true state of the case remained in doubt till the boy died, '
420 OBSERVATIONb ON RUPTURES.
at which time both the swellings were become inanifesliy less
than they had been.
I opened his body, and examined the parts with some care.
The tunica vaginalis testis was open to the abdomen, and con-
tained a considerable portion of omentum, which portion reached
quite down to the testicle, but did not adhere to it: in the mid-
way, between the abdominal opening and the testis, the hernial
sac was so contracted, that the piece of caul, embraced by the
contraction, was not extricable by any force, and was pressed into
a firm, hard substance: above and below, it was soft and expan-
sile, but void of fat, as in all emaciated subjects. This hernia,
therefore, added to its other particularities, must have been inca-
pable of reduction without an operation.
Much about the same time, Mr. Reiley, a very ingenious gen-
tleman, who was then under me at St. Bartholomew's, showed
me a congenial hernia in a child he had then in dissection, and
in which a portion of intestine was begirt in the same manner, so
as to be perfectly inextricable but by division of the part.
Had the child lived, and, at any time, been under a necessity
of submitting to the operation for a bubonocele, this stricture,
made by the sac only, and independent of the abdominal tendon^
might have proved a very embarrassing circumstance in the ope-
ration, and have occasioned a difficulty which might not have
been foreseen; indeed, upon a view of it after death, it appeared
wonderful, how the intestine had executed its otfice during the
child's short life.
CASE XV.
Thomas Lever, a lad about seventeen years old, was sent to
St. Bartholomew's by Mr. Gray, of Colchester. His complaint
was a rupture, which prevented his getting his bread, and which
nobody in the country had been able to reduce.
The account he gave of himself was as follows: That he had
had the rupture as long as he could remember; that it had always
been down in the day, and up in the night, until within about six
months past, when he had been thrown over a horse's head, and
QBSERVATIONS ON RUl'TURES. 421
bruised against the pummel of the saddle; that the blow gave him
so great pain at the time as to occasion his swooning; that the
pain continued some hours, and was followed by inliammation
and swelling, which lasted some days; and that, from that time,
he had never been able to get his rupture up.
The scrotum was large and full, but not at all tense: it plainly
contained a portion of intestine, but there was no symploin, nor
any appearance of the smallest degree of stricture. Upon attempt-
ing reduction, some part of the gut passed easily and freely into
the abdomen, but a considerable portion of it remained, nor could
by any means be made to follow. The testicle was very distin-
guishable below, and seemed to be of its natural size, and in a
natural state, except that from the epididymis there proceeded a
small, hard body, which body became tight when the returnable
part of the gut went into the belly, and seemed to be what hin-
dered the return of the whole. The boy was in perfect health,
had no obstruction to his discharge per anum, nor any complaint
relative to the intestinal canal. A part of the intestine was, as I
have already said, returnable with the greatest ease; but even
this would not remain a moment after the finger which returned
it was removed, not even in a supine posture. A complete re-
duction was found impracticable — the parts were in such a state,
that no benefit could be proposed from evacuation of any kind.
To put a truss on was not only useless, but mischievous; and to
leave a boy of seventeen, who was to get his bread by hard la-
bour, with his scrotum loaded with intestine, liable, by every ex-
ertion, to be increased, and by any inflammation to become stran-
gulated, could not be thought of.
It was therefore, after very mature deliberation, deemed ad-
visable to give him the very probable chance of a cure by an ope
ration.
The very easy return of part of the gut into the belly convinced
me, that I must not expect to find any fluid in the sac: and the
boy's own account satisfied me that the hernia was congenial,
and had the tunica vaginalis for its sac.
I made my incision very cautiously, and found both these cir-
cumstances to be true. In the bag was a small portion of the
ileum, and that part of the colon called the caecum, with its ap-
422 OBSEKVAIIOWS ON RUPTURKis.
pendicuia vci'miformis: the former was loose, but the latter was
adherent io (he epididymis and testicle. It took some little time
to separate these connexions in such manner as to injure neither
of the par!s; but when that was accomplished, a very small di-
vision of the tendon served to obtain a complete reduction of the
whole, and the boy went home well in about six weeks.
If this lad liad not undergone the operation at the time he-did,
and inllaraniation \vi(h shicUire had, at any future time, attacked
him, his chance of preservation would have been but small. The
adhesion would have rendered reduction impracticable; but this
not being known, would have at least occasioned a waste of time
in unnecessary, fruitless attempts, &c.; unless it maybe supposed
that, after such attack, ihe intestine could be rendered pervious
and capable of executing its office by means of purging and stimu-
lating medicines, (which in this situation of things I am not much
inclined to believe,) it is clear, that nothing but the operation
could iiave served him; which operation (the circumstance of ad-
hesion not being known) would not in all probability have been
proposed one minute too soon. Besides which, when all the parts
were got into a state of infias'amation, the separation of the cohe-
sion might not, perhaps, have been executed so readily.
A case, in some degree like to this, was in St. Bartholomew's
about a year ago, under the care of Mr. Younge. It was in a boy
about eleven years old. His scrotum was much enlarged, and
contained something of considerable size; but there was neither
pain, iniiammalion, tension, nor impediment, in going to stool.
Notwithstanding the absence of all bad symptoms, the boy, from
the mere size of the tumor, was prevented from doing any thing,
either by way of exercise or work.
The operation was performed: the hernia, which vvas conge-
nial, was both intestinal and omental. 1 am sure I am within the
truth when I say, that there were ten different adhesions of the
omentum to the sac, and two to the testicle: nor was this all, for
the upper part of the sac was so narrow, that it might well have
been mistidcen for a stricture made by the tendon.
Had the portion of intestine in this case been at any time in-
creased, so as to have produced a stricture, bad symptoms would
OBSERVATIONS ON RUPTUFJiS. 423
soon have come on, and what (.rouble might not have been expect-
ed from parts so circumstanced, not one of which couki liave been
known previously to the operation? >
A sudden attack of great pain in t'ne belly, attended with sick-
ness and vomiting, and an incapacity of going to stool, imply the
probability of a rupture being the cause; especialiy if the person
so attacked either has at that time, or has had, one.
Pain in the belly, nausea, vomiting, and constipation, are the
general symptoms of an obstruction in some part of the intestinal
canal, and denote, among other things, a perversion, alteration,
and, perhaps, sometimes, cessation of its. peristaltic motion. They
do not indeed point out what the particular cause may be; but,
let it be what it may, if it be not soon removed, the patient must
sink.
An incarcerated hernia, as it is called, is a disease caused by
such stricture made on a part of the intestinal canal, as not only
stops its proper motion, and prevenis the passage of the faeces
through it, but also hinders the circulation of blood through its
vessels, and very soon induces a mortification.
The same symptoms have sometimes been produced by an in-
flammation, or by a spasmodic aftection of the same part in per-
sons who, if they have had a hernia, have not had any s!ricture
in it; and also in persons who have had no hernia at all.
The great and material difference between the two cases is, that
in the one the symptoms are occasioned by an affection of a part
of the intestinal tube thrust forth from lis natural situation within
the belly, and begirt by a stricture; and, in the o-lher, they arise
from an affection of a part of the same canal, not begirt nor thrust
forth, but remaining in its proper place. The general complaints
attending each of these diseases are so alike, and are so very diifi-
cult to be distinguished from each other, that whenever they ap-
pear to any violent degree, the places in which hernijB make theij*
appearance, ought always to be inquired into or esamined,. more
especially in women; for, although the symptoms resemble each
other so much, the causes of them are materially different, and ren-
der one an object of surgery, while the other is not at all so.
Whoever reflects on these facts must see the propriety, or indeed
424 OBSERVATIONS ON RUPTUREb.-
the necessil}', of such inquiry as may determine tbe true nature ot'
the malady; that a rupture, if it be the cause, may be immediately
reduced; or, ihat not being the case, that the passio illiaca may be
properly treated.
These circumstances are such, that the hazard or safety of the
patient often depends upon them, and therefore require the very
serious attcnllon of the practitioner: but, material as they are,
they are not all: there are others which equally demand his
regard.!*
A rupture doth not preclude or prevent inflammation or spasm,
or whatever else may be the cause of mischief, from attacking any
other part of the intestinal canal not included within the hernial
«ac; neither doth it prevent the same kind of evils from falling on
that part of the intestine which is within the sac, and thereby pro-
ducing mischief independent of the rupture, although affecting the
part within, or causing it. And it also sometimes happens, that
persons afflicted with unreduced or irreducible ruptures, are ren-
dered incapable of discharging their faeces per anum, by causes
y>fhich have not the least connexion with, or dependence upon the
rupture, or the intestine contained within it. Thus it becomes a
surgeon's care to endeavour to be able not only to know when a
hernia is the cause of bad symptoms, but also when it is not; as
his conduct upon these different occasions must be very materially
different: for, on the one hand, if the mischief arises from the in-
testine being bound by a stricture, nothing but the reduction of it
by the hand, or the setting it free by the chirurgic operation, can
preserve the patient; but, on the other, if the symptoms proceed
from another cause, even though the portion of intestine within the
hernia should be the immediate seat of the evil, the attempts for
reduction will be painful and vain, the operation at best useless,
and most probably prejudicial; and, if the seat and cause-of the
mischief be not within the rupture, both the last mentioned at-
tempts become thereby still more improper, more useless, and
more pernicious.
P Tlie observation of Platner, who says, "Nee facile liiveniuntur notze qu<e
' ostenduut ex qua occasione intes'dna laborant," is strictly just and true.
OBSERVATIONS ON RUPTURES. 425
CASE XVI.
An old gentleman, who bad for many years had an irreturnable
rupture of the mixed kind, and which I had often seen, was
seized with the symptoms of an obstruction in the intestinal canal.
He complained of great pain in his whole belly, but particu-
larly about his navel. He was hot and restless, and had a fre-
quent inclination to vomit; his pulse was full, hard, and frequent;
and 'he had gone, contrary to his usual custom, three days without
a stool.
I examined his rupture very carefully; the process was large and
full, as usual, but not at all tense or painful upon being handled;
his belly was much swollen and hard, and he could hardly bear
the light pressure of a hand about his navel. Upon mature con-
sideration of the whole, I was of opinion that his rupture had no
share- in his present complaints. But as some of his symptoms
resembled those of a stricture, I desired that more advice might'
be had. A physician and surgeon were called: I gave them an
account of what I had seen of the case, of ray opinion concerning
the irreducibility of the rupture, and that it had no share in the
present complaint: at the same time desiring my colleague to ex-
amine for himself. We tried at reduction without success, but
he thought that there was still a stricture. The doctor ordered
bleeding, clysters, and cathartics: the last were immediately re-
jected by vomit, and the clyster came away without any mixture
of faeces. Bleeding was repeated ad deliquium; the tobacco-
smoke was injected, but all to no purpose. The operation was
proposed; but as the case did not appear to me to require it, I
could not second the motion: it was, however, mentioned to the
patient, who would not consent unless I would say that 1 (bought
it necessary, and believed it would be successful: I could not say
either, because I believed neither. Every thing else that art
could suggest or practise, was tried; but on the sixth day he died.
As it had been supposed that I was wrong and positive, I was
very glad that his friends chose to iuive him opened.
The hernial sac was thick and hard, and contained a large por-
VOL. I. 3 H
436 6BSfeilVAtlONS ON RUPTURES.
tion of omentum, a piece of the ileum, and a portion of the colou,
all perfectly sound, free from inflammation or stricture, and irre-
turnable only from quantity. But the intestine jejunum was
greatly distended, highly inflamed, and, in some parts, sphace-
lated.
CASE XVII.
John Dewell, a man about thirty, was brought into Sf. Bar-
tholomew's, labouring, as was supposed, under an incarcerated
hernia. He had not had a stool for three days, . although he had
taken both purges and clysters: he vomited almost incessantly,
his pulse was hard and frequent, but not full, and his countenance
bespoke death.
He had a rupture; it was on the right side, was clearly intes-
tinal, was soft, easy, occasioned no pain upon being handled, and
seemed to be capable of reduction; but after many trials, I found
that I could not accomplish that end, notwithstanding I used my
utmost endeavours; all which gave the man no uneasiness, and
therefore satisfied me, that his symptoms did not arise from his
hernia, which was also the patient's own opinion.
Mr. Nourse coming into the ward, I desired him to look at the
man: he thought that, notwithstanding the seemingly quiet state
of the rupture, a small portion of gut might be so engaged, as to
cause his present mischief, and therefore that the operation was
warrantable and proper.
Supposing it to be right at all, it could not be done too soon,
and therefore we set about it immediately.
The hernial sac was formed by the tunica vaginalis: it contain-
ed a portion of intestine ileum, which had contracted a slight co-
hesion with the testicle, but was so perfectly free from stricture,
that, when we had loosened it from its connexion, we returned it
into the belly without dividing the tendon.
I was indeed afraid that the man would have died before we
could have got him to bed, but he lived till the next day.
A portion of the colon within the belly had been in a state of
inflammation, was now plainly mortified, and quite black.
OBSERVATIONS ON RUPTURES. 427
CASE XVIII.
I vVas desired to be present at the opening of the body of a
gentleman, whose disease and death had occasioned some alter-
calion among those who had attended him.
The account given of him while living was, that to the age of
fifty-six he had enjoyed an uninterrupted state of health.
That, at the age of forty, he discovered a rupture, for which he
immediately took advice, and put on -a truss. That the truss not
answering the purpose, he soon threw it aside, and suffered his
rupture to take its course. That it gradually increased until it
became both visible and troublesome. That he then applied to
Mr. Sainthill and Mr. Samuel Sharpe, both of whom endeavoured
to reduce it, but in vain, and both advised him to wear a suspen-
sory bag, which he, from that time, had constantly done. That
from that time he had never complained of any uneasiness but
what was occasioned by its mere weight. That he verj" seldom
missed having a stool every morning. That about two years be-
fore his death, he began to complain of frequent pain about his
bladder and fundament. That these pains had affected him near
three months before he found any alteration in his fsecal dis-
charge; but that from that time he had been constantly costive;
and for the last six months had never passed a stool without a
very stimulating purge, and even then with great difficulty. That
he had frequently taken advice, had a variety of medicines pre-
scribed, from none of which he ever reaped any other than the
temporary benefit of purging. That in all this time no alteration
bad ever been found or perceived in his rupture, either regarding
its size, or any other circumstance. That for seven or eight
weeks before his death, he had worn a very morbid aspect, was
become extremely emaciated, and had totally lost all appetite; his
pains also being more frequent and more acute. And that, for the
last week, he neither had, nor could obtain, any the smallest de-
gree of stool.
This symptom had been, by those who were called to him last.
428 OBSERVATIONS ON RUPTURES.
attributed to his hernia; and the operation had been much pressed
pn one side, and objf cted to on the other.
The Ijernial sac was old, large, and thick; its contents (omen-
tum) much hardened; and a considerable portion of the intestine
ileum both perfectly sound and unaltered, and not bound by the
smallest degree of stricture. The stomach, liver, spleen, and
small intesiines, without blemish, but considerably disiended; but
about five inches of that part of the colon nearest to the rectum
was so contracted, that it was quite impervious; and so hardened,
that it was like nothing so little as a portion of gut.
CASE XIX.
A MAN, about forty, was brought to St. Bartholomew's with a
supposed incarceraied hernia.
He had a very swollen, tight belly, a frequent pain and vomit-
ing, and no stools; and this had been the case for three days, during
which time very proper attempts had been made both for reduction
and passage.
Nci.her the scrotum, nor the parts about the groin, seemed to
indicate that the seat of the evil was there, ah bough the parts
were certainly too tense, and a portion of iniestine was palpably
in a hernial sac. It was Mr. Crane's week, who was out of
London; and Mr. Edmund Pitt, who acted for him, desired me to
assist in the operation, which was thought necessary, as no dis-
charge per anum could be procured.
The hernial sac was of the congenial kind, and contained a
portion of small iniestine, which did not seem much, if at all,
bound by the tendon, but it was so strongly and universally ad-
herent to the neck of the sac, thatit was impossible to think of
separating it. A very unpleasant circumsumce this. All that
could be done was, to set it free from ail possible slriciure,
and, if siools could be procured, to act afterwards as might be
necessary.
Every means, of purge, clyster, &c. was used, but no pass-
age procured; and on the fourth day from that of his admission
he died.
OBSERVATIONS ON RUPTURES. 420
The piece of intestine, in the hernia, was that part of the ileum
nearest to the colon, and which was in good order, only adherent;
bill higher up, toward the j(;jnnum, it was absolutely impervious
for more than three inches in lengih.
I have seen two other cases so nearly similar, that I need not
repeat them.
The following case has some circumstances which may possibly
be worth the reader's notice.
CASE XX.
Thomas Marshall, aged fifty-four, was brought into St.
Bartholomew's hospital, on the 25lh of May, 1764, with a large,
painful, tumefied scrotum. The account which he gave of him-
self was —
That in his childhood, he had been afflicted with a gut-rupture,
for which he had worn a truss until the rupture was supposed to
have been cured. That he had always been a regular, temperate,
and hard-working man. That, on the 23d of April, he fell, while
he was at work, a sudden, violent attack of a colic-pain, which,
in a few hours, was followed by a slight purging. That, his pain
not ceasing, he took some tincture of rhubarb, from which he had
three or four more motions. That, in the evening of the second
day, he found a considerable swelling in his groin and scrotum, on
the side where his rupture had formerly been. That, on the third,
he went to work again, although he had much pain in his btliy,
and a purging. That, on the fourth, he took something of ihe
cordial kind, given him by a neighbour, and staid at home all that
day and the next, during which he was pretty easy, but had
several loose stools. That, on the seventh day from that of his
being first taken ill, he went to work again, but was again attack-
ed with severe pain and frequent vomiting: immediately after
which, he found the swelling in his scrotum considerably increas-
ed. That, from Uiis time, he was so much and so constanily
uneasy, as to be obliged to keep his bed, ii being the only place
in which he could put himself in a tolerably eas} posture. And
that during ihe whole time, from the 29lh of April to the 25th
430 OBSERVATIONS ON RUPTURES,
of May, he had very seldom had less than two stools eVery day,
often more.
The man was much emaciated, had a quick pulse, a hot skin,
and considerable thirst: the scrotum was now very much on the
stretch, hegan to put on a purple kind of colour, and had, at the
same time, a watery load in its cellular membrane; but palpably
contained a large quantity of Huid in the tunica vaginalis testis.
The whole tumor had a pyriform kind of figure; the spermatic
process was hard and large, and clearly contained something
which passed into it from the belly; but which sometliing did not
descend below the upper part of the scrotum, while the lower part
of the saiiae was so distended, as to be half way down the thigh,
and was palpably filled by a fluid.
The state of the parts was such, that it became necessary to do
something, lest they should mortify. I made, with all possible
caution, an incision through the loaded integuments into tlie cavity
of the tunica vaginalis, and gave discharge to near a quart of the
most offensive brown liquor: upon the discharge of this, the lower
part all subsided, but the upper remained the same. I then, with
a crooked probe-pointed knife, divided the whole from below
upward, and found that the bag containing the fluid was a conge-
nial hernial sac, whose internal surface had all the appearance of
being mortified; and that the body, in its upper part, was a portion
of intestine. This portion ha(^, on its surface, several black and
truly sphacelated spots; some larger, and some smaller; but the
gut was still entire, and appeared moderately distended with wind,
1 passed my finger through the opening in the abdominal muscle,
and could not find that it made the smallest degree of stricture;
but found, at the same time, that the intestine was so firmly adhe-
rent to the sac, that, in its present state, it was equally impossible
to return, as to detach it. That night the man had two good
stools; and next morning, when I expected to have found him
dead, he was considerably better.
I again examined the parts, to see whether the intestine could
be returned; but again found that, had it been advisable, it was
impracticable. The third day he was still better, and had a
figured stool.
As it appeared highly improbable, that the mortified spots on
OBSERVATIONS ON RUPTURES. 431
the gut should cast off without leaving a breach in the intestine,
I thought that the best that could happen, would be a discharge
of faeces through the wound, at least for a time: but I was mis-
taken; for at the end of five days, during which he had taken the
bark freely, all the eschars cast off, by a florid good incarnation;
and, leaving no breach at all, the man became easy, cheerful, and
began to take nourishment.
From this time, the portion of intestine in the groin seemed
daily to retire upward, and become less visible; and I began to en-
tertain hope that we should see a very fortunate termination of
this very miserable case. For the space of ten days he took the
bark freely, and seemed every day better and better; but at the
end of that time, he became again feverish and languid. Instead
of his usual freedom of stool, none could be procured, and he
died.
The prolapsed gut had retired so much, that, had the man liv-
ed, I make no doubt that it would have been included within the
sore, and been firmly healed over: the places which had been
sphacelated were quite healed; but about four inches of that part
of the intestine, which was just within the belly, was so contracted
as to become quite impervious, and perfectly scirrhous.
The intelligent will, I make no doubt, remark on some parts
of this case; and therefore I shall trouble him with one only,
which is, that sphacelated spots on the surface of an intestine are
not always, and absolutely, a prohibition against returning such
intestine into the belly.
CASE XXL
I WAS desired to meet Dr. De Valangin, Mr. Godman, and Mr.
Bbigue, in the case of a hernia with stricture.
The patient was a man about the middle of life; his rupture
was, I think, on his left side; and when I saw him he had not
had a stool for several days, though the usual means had been
used. Upon examining the parts, they made as bad an appearance
as possible: they had been tumid, full, and inflamed; they were
now sunk, flaccid,^ and completely mortified: notwithstanding
432 OBSERVATIONS ON RUPTURES.
which, I could not say that the man appeared so near to death as
such an appearance would indicate; but at the same time so ma-
terially ill that I could not suppose that he could receive any
ben'-fit from the art of surgery.
The true intent of the operation, that of setting the gut free from
the stricture, was of no consideration here: the stricture had done
all its mischief: if the man was to live, (he mortified parts must
cast off; and if he was to die, I thought it was better that we
should not even appear to have a share in his death, by an opera-
tion which I thought could not be serviceable, and might be mis-
construed.
This was truly my opinion, and I gave it as such. But, over-
come bv the importunity of the patient's wife, and to avoid seeming
to be either careless or brutal, I was prevailed on to divide the
parts. The scrotum, integuments in the groin, and hernial sac,
were completely and truly mortified; the por'ion of intestine, which
certainly was not less than three inches, was in the same state,
sunk, empty, (having burst,) and as black as a coal; the offence
was terrible, but the man suffered no pain, as the parts were totally
void of sensation.
I contented myself with merely dividing the scrotum and hernial
sac, and left the rotten intestine as it was, lying in the groin on
the outside of the ring, concluding that a verv short space of time
would determine the poor man's fate, and that not favourably.
The gentlemen whom I had met continued to attend, and to take
care of him; the mortified parts cast off, he discharged his faeces
through his wound for some time, but that, in no great lengih of
time, ceased; and within the space of a month, I saw him in very
good health, discharging all his fagces per anum, and having only
a small, clean, and healing sore, where his wound had been.
How the faeces passed from the ileum to the colon, after the mor-
tified parts were thrown off, I am, considering the size of the
portion of gut, really at a loss to account for; but very sure I
am, that, if the advice given by all writers, in these cases, to cut
off the piece of mortified intestine, and fasten the sound part to the
upper part of the wound, had been followed, the man would have
passed the remainder of his life in a much more unpleasant man»
ner.
OBSERVATIONS ON RUPTURES. 433
HERNIA VESICJE URINARIA.
A HERNIA formed by a protrusion of a portion of the urinary
bladder through the opening in the abdominal muscle into the
groin or scrotum, is a disease sometimes, but not very frequently,
met with.
It has been taken notice of by many writers of character, and
has been accurately described by Mons. Verdier, and Mr. Samuel
Sharpe.
Whoever is acquainted with the structure and disposition of the
peritoneum, without which knowledge he cannot understand a
hernia at all, knows that the bladder is only covered in part by
that membrane, and that its inferior and lateral parts lie on the
outside of it, in the tela cellulosa.
That portion of the bladder which is liable to this protrusion,
is not covered by the peritoneum; consequently, when it is thrust
forth, it does not carry with it any part of the said membrane;
and therefore cannot have what is called a hernial sac; in which it
differs from every other kind of hernia.
The two following are the only cases I ever met with.
CASE XXII.
A POOR fellow, who worked with a farmer at Islington, came
to St. Bartholomew's with a large, troublesome swelling in his
scrotum. The tumor was large, tense, of a pyriform figure, pal-
pably contained a fluid, gave no pain but from its weight when
full, and had every mark of a hydrocele, except that the testicle
was perfectly distinguishable at its bottom.
While I was hesitating concerning this circumstance, the man
said, ' Sir, I can get rid of it all by pissing, but it fills again in a
a few hours, especially if I drink. '
Upon my seeming to disbelieve what he said, he took up his
scrotum, and squeezing it together with some violence, discharged
the whole by the urethra.
VOL. I. 3 I
434 OBSEKVATlOiXS ON IIUPTL'RES.
CASE XXIIJ.
A i!Ov, iiboiit six years okl, was seized with au acute pain about
the region of ihe pubes: it lasted near an hour and a half, and
suddenly ceasing, he became perfectly easy. During the time
his pain lasted he could not discharge a drop of water, though he
endeavoured so to do; but as it ceased he pissed freely. In a few
days after, a small tumor was discovered about the size of a pea,
in the spermatic process, just below the groin: it gave the child
no pain, and therefore no notice was taken of it. By slow de-
grees it descended lower and lower, and as it descended, it seem-
ed to increase in size. When it had got to the upper part of the
scrotum, it was observed to be considerably enlarged; and the
Iwy now found himself more frequently urged to make water, but
without pain or diffiulty. He was examined by a practitioner or
two in his neighbourhood, who, not knowing what to make of it,
advised the letting it alone. Withhi the space of five years it
got down to the bottom of the scrotum, and when it was there it
was observed to increase much faster than it had done before.
The boy Vv^as at a considerable distance from London, and it ill
suited his friends to send him thither, so that another year passed
before lie was sent up; which was done at the age of thirteen, the
swelling being now troublesome upon any motion.
Some, who first saw him, deemed it a scirrhous testicle, and
advised castration, to which the friends of the boy would not
submit.
From the most careful examination I could make, I could not
think it was formed by the testicle; but on the other hand I could
not find any testicle on that side.
The swelling was perfectly equal in its surface, was indolent,
had a stony, incompressible kind of hardness, was troublesome
from its weight, but never occasioned pain in the back or loins:
it had all the appearance of being dependant from the spermatic
process; which process, though it had neither the feel, nor the ap-
pearance of being diseased, yet was larger than it should be, and
than that on the other side. The perfect equality of the tumor.
OBSERVATIONS ON RUPTURES. 435
its being perfectly free from pain, even ivhen pressed harcl, and
its extreme incompressibilily, led rne to believe it war, not the tes-
ticle; but this was merely negative informalion. The trouble it.
now- gave the boy, and ils disposition to increase, seemed to au-
thorise its removal; and the state botli of the part and of the child
were no prohibitions. 1 therefore proposed and undertook it. j
made an incision through the skin and cellular membrane, the
whole length of the process and scrotum, by means of which I
discovered a firm, white, membranous bag, or cyst,- connected
loosely with the cellular membrane, in the same manner as a her-
nial sac. I dissected all the anterior part of this bag quite clean.
. and found that, as I traced it upward, it became narrower, and
seemed to proceed from the upper part of the groin. This deter-
mined me to try if I could not clear it from its posterior con-
nexion; in doing which, I discovered a testicle which lay immedi-
ately behind the body forming the tumor, and was small, (lat, and
compressed.
The dissection of this, and of the spermatic chord from the
bag and from its neck, which I was obliged to do in order to pre- .
serve the testicle, took up some time, and gave me some trouble;
but when I had finished it, I found that the cyst was dependant
from, and continuous with, a membranous duct about the breadth
of the largest wheat-straw, or what it was more like to, a human
ureter? which passed out from the abdomen through the opening
in the muscle.
When I had pe*fectly cleared this duct from all connexion with
the spermatic chord, I cut it off immediately above the tumor;
and upon the division there issued forth about four ounces of
a clear liquor; and the mouth of the cyst, expanding itself,
disclosed a stone, exactly resembling what is found in the human
bladder.
As there was not the least appearance of fluid, either in the bag
or in its neck, before the division, its immediate effusion, and the
appearance of the stone, induced me to believe, that the case was
a hernia cystica. In order to be certain, I staid some time; and
when I thought that some quantity of urine might have passed
from the kidneys. T desired the boy to try to make water: he did
436 . OBSERVATIONS ON RUPTURES,
SO, and a large stream of urine flowing through the wound, in-
stead of the urethra, put the matter out of all doubt.
He was dressed superficially, had no one bad symptom, though
a portion of the bladder was totally removed: his urine came
through the wound in his groin for about a fortnight; but as
that wound healed, it resumed its natural course, and the pa-
tient has remained free from complaint ever since, except that
the natural size of his bladder being lessened by the extirpa-
tion of a part, he is obliged to discharge his uiine rather more
frequently.
CASE XXIV.
AN OVARIAN HERNIA.
A HEALTHY youug womau about twenty-three was taken into
St Bartholomew's hospital on account of two small swellings, one
in each groin, which for some months had been so painful, thai
she could not do her work as a servant.
The tumors were perfectly free from inflammation, were soft,
unequal in their surface, very moveable, and lay just on the out-
side of the tendinous opening in each of the oblique muscles,
through which they seemed to have passed.
The woman was in full health, large breasted, stout, and men-
struated regularly; had no obstruction to the discharge per anum;
nor any complaint but what arose from the uneasiness these tumors
gave her, when she stooped or moved so as to press them.
She was the patient of Mr. Nourse. He let her blood and
purged her, and took all possible pains to return the parts through,
the openings through which they had clearly passed out.
He found all his attempts fruitless, as did Mr. Sainlhill and
myself; and the woman being incapacitated from getting her bread,
and desirous to submit to any thing for relief, it was agreed to
remove them.
The skin and membrana adiposa being divided, a fine mem-
branous bag came into view, in which was a body so exactly re-
sembling a human ovarium, that it wa"? impossible to take it for
OBSERVATIONS OW IW L'TU RLH . 437
iinj thing else; a ligature was made on it, close io the tfcndon,
and it was cut off. The same operation was done on the other
side; and the appearance, both at the iime of operating, and in
the examination of the parts removed, was exactly the same.
She has enjoyed good health ever since, but Is become thinner
and more apparently muscular; her breasts, which were large,
are gone; nor has she ever menstruated since the operation, which
is now some years.
EJNfe OF VOL. 1.
COLUMBIA UNIVERSITY
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